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ILLUSTRATED 



SKIN DISEASES 



AN ATLAS AND TEXT-BOOK 

WITH SPECIAL REFERENCE TO MODERN DIAGNOSIS AND THE MOST APPROVED 

METHODS OF TREATMENT 



BY 

WILLIAM S, GOTTHEIL, M.D. 

VISITING DERMATOLOGIST TO THE CITY HOSPITAL AND TO LEBANON HOSPITAL ] CONSULTING 

DERMATOLOGIST TO BETH-ISRAEL HOSPITAL; FELLOW OF THE N. Y. ACADEMY OF 

MEDICINE; MEMBER OF THE MANHATTAN DERMATOLOGICAL SOCIETY, THE N. Y. 

COUNTY MEDICAL SOCIETY, AND THE AMERICAN MEDICAL ASSOCIATION, 

ETC. ,* ETC. 




SECOND EDITION, REVISED AND ENLARGED 

NEW YORK 
E. B. TREAT & COMPANY 

241-243 WEST 23D STREET 

1906 



I LIBRARY of C0N6HESS 
Two Copies Received 
MAR 12 1907 

Copyright Entry 

CLASS O. XXc.No. 
/IOC, 02- 
COPY B. 






Copyright, 1897, 1902, and 1905, by E. B. Treat & Co. 



PREFACE TO SECOND EDITION. 



In the attempt to make a general survey of a branch of medicine so young and 
so rapidly growing as Dermatology there are difficulties that do not occur in older 
and more thoroughly explored fields. In cutaneous medicine the description and 
differentiation of new maladies, and the correlation and grouping of older ones, are 
still in progress ; and the limitations and boundaries of its various subdivisions are 
still matters of discussion. Classification, upon whatever basis it may be made, is 
necessarily imperfect, for both the etiology and the pathology of many dermal mal- 
adies are still unsettled. Even the nomenclature presents difficulties of its own. In 
some cases dissimilar diseases are known by similar names, and in others the desig- 
nations of a single malady are varied and confusing. 

In the following pages the field of dermal disease has been covered only so far 
as it is necessarily of interest to every practitioner of medicine. The nomenclature 
employed is that in common use. The classification that is followed is the simple 
pathological one recommended by Jessner, which seems to be as good as any one at 
our disposal to-day. Especial stress is laid upon the Symptomatology, Diagnosis, 
and Treatment of the various diseases, while the less practical considerations of Eti- 
ology and Pathology are condensed and cursorily considered. Questions that are 
still matters of dispute in Dermatology have been, as far as possible, avoided. No 
attempt has been made in the therapeutic sections to mention all the measures and 
plans of treatment that have been found useful in the various diseases. The stan- 
dard modern methods, and more especially those that the author has himself found 
useful, have been recommended. It is^ hoped that the simplified and systematized 
arrangement of the prescriptions will be found useful. 

Pictorial representation, a recognized aid to the practitioner in every department 
of medicine, is of preeminent importance in Dermatology. Most of the symptoms 
are objective and visual, and the diagnosis must generally be made by the eyesight 
alone. It is difficult to represent in words the manifold impressions and the delicate 

3 



4 PREFACE. 

variations that are so readily appreciated through the optic nerve. Many attempts 
have been made to depict on paper and permanently preserve the evanescent 
features of dermal disease. Photography and its dependent processes are the most 
suitable means for that purpose ; for the artist's brush necessarily reflects his own 
individuality, and his work is influenced by factors so many and various as to make 
it unsuitable for reproduction in quantity. Colored illustrations have been intro- 
duced in this atlas in all cases in which they have seemed to be necessary or 
advisable ; but in the many instances in which color is of no importance for the 
recognition of disease, illustrations in black and white have been supplied. 

The pictures, both plate and text, have been selected with the view of exhibit- 
ing, as far as possible, the ordinary phases of skin disease as met with in practice. 
Most of them are from photographs of his own patients made by the author. Those 
that are not are credited to the physicians from whom they came. A few are taken 
from foreign sources. The anatomical illustrations are from photomicrographs. 

In this second edition the section on Cosmetics of the Skin and Hair has been 
entirely rewritten and very greatly enlarged ; for the author believes that it is the 
neglect of this field which has permitted it to fall to so large an extent into im- 
proper and non-medical hands. The number of prescriptions has been considerably 
increased ; and the various changes which the improvement of our knowledge of 
the nature, pathology, and treatment of certain dermatoses render necessary have 
been made. 

The author desires to express his thanks to Drs. T. E. Oertel and William 
Beurman for assistance in the preparation of the plates, and to Dr. J. F. Aitken for 
his hearty good will and help in the collection of material. He also desires to thank 
Professor Elsenberg of Warsaw, Poland, Drs. Salvador Garciadiego of Guadalajara, 
Mexico, A. H. Ohmann-Dumesnil of St. Louis, A. Ravogli of Cincinnati, Ludwig 
Weiss, F. B. Carpenter, Robert Abrahams, Henry Roth, and Louis Fischer, of New 
York City, for the photographs and cases that they have placed at his disposal. 

William S. Gottheil. 

January I, 1902. 



CONTENTS. 



PAGE 

Anatomy of the Skin 13 

Physiology of the Skin 29 

Classification 52 

Class I. Functional Disorders.... 54 

Pruritus 54 

Hyperidrosis 56 

Sudamina 60 

Seborrhea 61 

Comedo 65 

Milium 67 

Sebaceous Cyst 68 

Asteatosis 69 

Class II. Non-inflammatory Circu- 
latory Disturbances 71 

Erythema Simplex 71 

Livedo 73 

Urticaria 75 

Prurigo 79 

Purpura 83 

Class III. Inflammations 86 

Morbilli 86 

Rubeola 87 

Scarlatina 87 

Variola 89 

Vaccinia 90 

Varicella 91 

Lichen Planus 92 

Lichen Ruber 94 

Favus 96 



PAGE 

Class III. Inflammations. — Continued. 

Trichophytosis Capitis 101 

Trichophytosis Barbae 105 

Trichophytosis Corporis 108 

Trichophytosis Cruris no 

Chromophytosis 113 

Scabies 116 

Phtheiriasis Capitis 120 

Phtheiriasis Vestimenti 122 

Phtheiriasis Pubis 1 24 

Eczema 125 

Erythema Multiforme 139 

Herpes 140 

Zoster 142 

Dysidrosis 144 

Pemphigus 145 

Dermatitis Herpetiformis ........ 149 

Impetigo Contagiosa 151 

Dermatitis Exfoliativa 152 

Psoriasis 153 

Dermatitis 159 

Erythema Nodosum 166 

Erysipelas 167 

Chancroid 170 

Furunculosis 173 

Carbunculus 175 

Tuberculosis Cutis 177 

Lupus Vulgaris 177 

Scrofuloderma 181 

Tuberculosis Cutis Verrucosa 184 

Chancre » 187 

Syphiloderma 190 



CONTENTS. 



PAGE 

Class III. Inflammations. — Continued. 

Lepra 215 

Mycosis Fungoides 219 

Lupus Erythematosus 221 

Rhinoscleroma 225 

Actinomycosis 227 

Hydradenitis 227 

Acne 228 

Rosacea 233 

Folliculitis ' 236 

Onychia 239 

Onychomycosis 240 

Class IV. Hypertrophies 241 

Ichthyosis 241 

Keratosis Pilaris 243 

Callositas 244 

Clavus 246 

Cornu Cutaneum 247 

Condyloma Acuminata 248 

Verruca 250 

Elephantiasis 251 

Molluscum Contagiosum 254 

Hypertrichosis 256 

Onychauxis 258 

Naevus Pigmentosus 259 

Lentigo 261 

Chloasma 262 



tagf. 

Class V. New Growths 264 

Cicatrix 264 

Keloid 265 

Fibroma 267 

Myxoma 268 

Neuroma 268 

Lipoma 268 

Xanthoma 269 

Sarcoma 270 

Myoma , 272 

Angioma 273 

Lymphangioma 2/6 

Adenoma 276 

Carcinoma 277 

Class VI. Atrophies 286 

Atrophia Cutis 286 

Scleroderma 289 

Sclerema Neonatorum 291 

Albinismus 293 

Vitiligo 293 

Canities 295 

Alopecia 298 

Alopecia Areata 304 

Atrophia Pilorum 307 

Atrophia Unguis 309 

Cosmetics of the Skin and Hair ... 311 



LIST OF PLATE ILLUSTRATIONS. 



PLATE Facing page 

I. Diagrammatic Section of the Skin 13 

II. Urticaria Papulosa 75 

III. Lichen Planus 95 

IV. Zoster Pectoralis ; Erythema Multiforme 143 

V. Purpura 83 

VI. Scarlatina 87 

VII. Dermatitis Exfoliativa 153 

VIII. Trichophytosis 109 

IX. Dermatitis Venenata 163 

X. Dermatitis Parenchymatosa , 165 

XL Favus 99 

XII. Variola; Morbilli 91 

XIII. Eczema Acutum 129 

XIV. Pemphigus , 145 

XV. Eczema Impetiginosum 125 

XVI. Eczema Palmae ; Syphiloderma Palmse 133 

XVII. Psoriasis 155 

XVIII. Psoriasis Circinata 157 

XIX. Psoriasis Diffusa 159 

XX. Syphiloderma Ulcerosum ; Cathode-ray Dermatitis 215 

XXL Erysipelas 169 

XXII. Impetigo Contagiosa 151 

XXIII. Chromophytosis 113 

XXIV. Ichthyosis Hystrix 271 

XXV. Lupus Vulgaris 177 

XXVI. Lupus Vulgaris 181 

XXVII. Syphiloderma Papulosum ; Syphiloderma Pustulosum 201 

XXVIII. Syphiloderma Tuberculo-ulcerosum 209 

XXIX. Syphiloderma Papulosum 193 

7 



8 LIST OF PLATE ILLUSTRATIONS. 

plate Facingpage 

XXX. Gumma Subcutaneum 211 

XXXI. Rupia Syphilitica 213 

XXXII. Syphiloderma Maculosum; Syphiloderma Gummatosum; Glossitis Syphili- 
tica ; Syphiloderma Papillosum 205 

XXXIII. Syphilodermata 189 

XXXIV. Naevus Pigmentosus 259 

XXXV. Perifolliculitis Barbae 237 

XXXVI. Ichthyosis ; Keratosis Pilaris 243 

XXXVII. Syphiloderma Papulosum 185 

XXXVIII. Elephantiasis Arabum 253 

XXXIX. Syphiloderma Pustulosum 197 

XL. Vitiligo ; Lymphangioma ; Keloid ; Fibromata 265 

XLI. Acne 229 

XLII. Rosacea 233 

XLI 1 1. Naevus Vasculosus 275 

XLIV. Alopecia Areata ; Alopecia Neurotica ; Alopecia Pityrodes ; Alopecia Totalis 299 

XLV. Alopecia Areata 305 

XLVI. Impetigo 149 

XLVII. Erythema Multiforme 1 39 

XLVIII. Elephantiasis; Sarcoma Pigmentosa ; Sarcoma Cutis; Tuberculosis Cutis 

Verrucosa 269 

XLIX. Leucoderma 293 

i.. Verruca ; Alopecia Areata 251 

LI. Eczema Seborrheicurn 131 

LII. Zoster Sacro-cruralis 143 

LIII. Scrofuloderma ; Lupus Hypertrophicus 179 

LIV. Rhinoscleroma ; Chronic Eczema ; Chromophytosis of Face 225 

LV. Comedo and Acne 65 

LVI. Dermatitis Traumatica 3 Dermatitis Herpetiformis 161 

LVII. Eczema Marginatum IIr 

LVIII. Eczema Seborrhoicum I2 j 

LIX. Psoriasis of the Nails; Onycholysis; Eczema Unguium; Leucony- 

china Striata j,* 

LX. Variola; three forms 8o 



LIST OF TEXT ILLUSTRATIONS. 



FIG. 
I. 

2. 
3- 

4- 

5- 
6. 

7- 

8. 

9- 

10. 

ii. 

12. 

13- 
14. 

16. 

*7- 
18. 
19. 
20. 
21. 
22. 

23- 
24. 

2 5- 
26. 
27. 
28. 



PAGE 



Epidermis, corium, and subcutaneous tissue Author 14 

Arrectores pilorum, hair-sacs, etc , 

Pacinian corpuscles, lymph-spaces, panniculus adiposis, etc 

Pacinian corpuscles, nerve-trunks, etc 

Sebaceous glands 

Sweat-glands and ducts 

Hair and hair-follicle 

Hair-shaft and root 

Transverse section of hair and sac 

Hair from head of female J. F. Babcock . 

Cross-sections of hairs from head " " 

Hair from head of child " " 

Hair from back of hand " " 

Transverse section of third phalanx Toldt . 

Scarificator Author . 

Comedo extractor 

Needle and holder for electrolysis 

Dermal curette 



Grappling forceps 

Epilating forceps 

Spear-shaped spud 

Keyes's cutaneous punch 
Dental bur 



!7 

18 

*9 
20 
21 
2 3 
24 

25 
26 
26 
26 
26 
27 
.5° 
5° 
5° 
5° 
5° 
5° 
5i 
5i 
5 1 
5 1 
5i 
5 1 
5i 
5 1 



10 LIST OF TEXT ILLUSTRATIONS. 

fig. PAGE 

29. Seborrhea capitis Author 62 

30. Comedo J. F. Aitken 66 

31. Comedo gigantica Author 67 

32. Sebaceous cyst 69 

2,2,. Urticaria gyrata " 75 

34. Urticaria factitia 76 

35. Urticaria pigmentosa Elsejiberg 77 

36. Prurigo Van Haren-Noman 80 

37. Purpura simplex Author 84 

38. Vaccinia _ " 90 

39. Varicella " 91 

40. Lichen planus " 92 

41. Favus corporis Ehenberg 97 

42. Achorion Schonleinii Joseph 98 

43. Favus capitis J. F. Aitken 99 

44. Hair and root-sheath affected with favus Kaposi 100 

45. Trichophytosis capitis Author 102 

40. 102 

47. Ringworm hair Kaposi 103 

48. Trichophytosis barbae Author 1 06 

49. Trichophytosis corporis " 1 09 

50. Dermatomycosis flexurarum " no 

5 1 . Pityriasis rosea J. F. Aitken in 

52. Trichophytosis cruris Author 112 

53 113 

54. Microsporon furfur Joseph 114 

55. Chromophytosis Author 114 

56. Erythrasma " 1 16 

57. Scabies " 117 

58. Acarus scabiei Kilchenvieister and Ziim, and Neumann 118 

59. Pediculus capitis Author 121 

60. Phtheiriasis vestimenti Van Haren-Noman 122 

6 1 . Pediculus vestimenti Kiichenmeister and Zilrn 123 

62. Pediculus pubis Author 1 24 

63. Embryo— Pediculus pubis " t 24 

64. Eczema papulosum , " 126 

65. Eczema vesiculosum Van Haren-Noman 127 

66. Eczema squamosum Author. . ,128 



LIST OF TEXT ILLUSTRATIONS. 11 

FIG. PAGE 

67. Eczema faciei Author 129 

68. Eczema of the hands " 130 

69. Eczema acutum " 131 

70. Eczema crustosum " 134 

71. Herpes febrilis " 141 

72. Zoster patch " 143 

73. Acute pemphigus " 146 

74. Pemphigus vulgaris " 147 

75. Impetigo contagiosa " 151 

76. Psoriasis guttata Ludwig Weiss 154 

77. Psoriasis diffusa Louis Fischer 155 

78. Psoriasis nummularis Van Haren-Noma?i 156 

79. Psoriasis gyrata Author 157 

80. Dermatitis traumatica - " 160 

81. Parenchymatous dermatitis " 161 

82. Parenchymatous dermatitis with ulceration " 161 

83. Dermatitis ambustionis bullosa " 162 

84. Dermatitis venenata " 163 

85. Chancroid " 170 

86. Chancroidal ulceration of labia " 171 

87. Ecthyma " 172 

88. Furunculosis " 173 

89. Carbuncle A. H. Ohmann-Dumesnil 175 

90. Lupus hypertrophicus Lesser 178 

91. Lupus vulgaris " 179 

92. Tuberculosis cutis Author 185 

93. Chancre " 187 

94. Exulcerated chancre " 188 

95. Chancre of the lip " 189 

96. Chancre of the meatus " 190 

97. General macular syphiloderm " 191 

98. General papular syphiloderm " 192 

99. Papular plantar syphiloderm " 193 

100. Condylomata lata " 1 94 

101. Large pustular syphiloderm " 196 

102. General pustular syphiloderm " 197 

103. Tuberculo-squamous syphiloderm " 198 

104. Hypertrophic tubercular syphiloderm Elsenberg 198 



12 LIST OF TEXT ILLUSTRATIONS. 

FIG. PAGE 

05. Superficial gummata Elsenberg 199 

06. Exulcerated gumma of the knee Author 199 

07. Gumma subcutanea 2 °° 

08. Ulcerative syphiloderm H. Roth 201 

09. Paronychia syphilitica Author 202 

10. Alopecia syphilitica Lesser 202 

1 1. Multiple gummata Author 204 

1 2. Lepra tuberosa S. Garciadiego 216 

13. Lepra mutilans Joseph 217 

14. Lupus erythematosus R. Abrahams 221 

15. " " " 223 

16. Acne punctata Author 228 

1 7. Acne pustulosa " 229 

1 8. Acne bromata Elsenberg 230 

19. Rhinophyma F. B. Carpetiter 234 

20. Folliculitis barbae Author 237 

2 1 . Folliculitis " 238 

22. Callositas " 245 

23. Cornu cutaneum " 247 

24. Condyloma acuminata " 248 

2 5- 2 49 

26. Elephantiasis vulvae Van Hare7i-Noma7i 253 

27. Molluscum contagiosum Author 255 

28. Onychauxis Va?i JJaren-JVbman 258 

29. Naevus pigmentosus Author 260 

30. Keloid " 266 

3 1 . Sarcoma cutis " 271 

3 2 . Naevus venosus " 274 

t,^. Papillary naevus " 275 

34. Rodent ulcer Ludwig Weiss 278 

35. Epithelioma of the penis Author 279 

36. Papillary epithelioma " 280 

37. Epithelioma of the lip " 281 

38. Fungating epithelioma of the scalp " 282 

39. Striae atrophies A. H. Ohmann-Dumesnil 287 

40. Leucoderma Van Haren-Noman 294 

41. Leucoderma Joseph 295 




COPYRIGHT BY E. B, TREAT & CO., N. Y. 



PHOTOGRAVURE AND COLOR CO., N. Y. 



DIAGRAMMATIC SECTION OF THE SKIN 



PLATE I. 



ANATOMY OF THE SKIN. 



ever 



present 

i 
,wi are :. 

■ 



. hi 



I 



■ 
id. 

ling 1 







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- 



TION OF THE SI 



ANATOMY OF THE SKIN. 



THE skin is an elastic and flexible membrane covering the entire body. Its 
structure is complex, and varies in different parts. Certain elements are present 
everywhere, and are essential portions of the organ ; such are the epidermis, the 
corium, and the subcutaneous connective tissue. Others are found only in certain 
regions, and are called appendages; as the hairs, the sweat and the sebaceous 
glands, and the nails. It contains also blood-vessels, lymphatics, and nerve- structures. 

Its appearance varies in different individuals and on different portions of the 
body. Its texture in places feels smooth and velvety, as on the forehead and on 
the lumbar regions ; in others, as on the outer surface of the thighs, it is rough and 
uneven. Its color depends on the amount of blood contained in the surface vessels, 
and on the pigment deposited in the epidermic layers. This latter varies in the 
different races, and is always more abundant around the nipples and on the 
genitalia. It is marked by deep furrows over the various joints, while secondary 
furrows further subdivide it into minute angular fields. At the junction of the 
angles of these fields are the pores, minute openings which mark the mouths of the 
hair-follicles and the sebaceous glands. Distinct ridges, corresponding to the regu- 
larly arranged papillae of the cutis, are found on the palms and soles. 

The skin is thickest on the back, buttocks, palms, and soles, and thinnest on the 
eyelids and the prepuce. It is in general more or less movable on the subjacent 
parts ; but in some places, as over the sternum and on the glans penis, it is more 
closely attached to the tissues beneath. Its entire surface is covered with hair; 
with ordinary long hair on the hairy parts, and with the fine down known as lanugo 
hair on the so-called smooth parts ; only the palms and soles, the dorsal surfaces of 
the third phalanges of the fingers and toes, the glans penis, and the inner surface of 
the prepuce being hairless. 

Finally, at the larger openings of the body the skin is directly continuous with 
the mucous membranes lining the cavities into which they lead. 

We distinguish three layers in the skin : I. The epidermis or scarf-skin, the out- 
ermost layer; 2. The corium, derma, or true skin, containing the glandular, muscu- 

13 



14 



ILLUSTRATED SKIN DISEASES. 



lar, vascular, and nervous structures; 3. The subcutis or subcutaneous connective 
tissue, containing the fat, the panniculus adiposus. 

We have also to consider the following special structures and appendages: 
4. The blood-vessels ; 5. The lymphatics ; 6. The muscles ; 7. The nerves, with the 
Pacinian bodies and the tactile corpuscles; 8. The pigment; 9. The sebaceous 
glands; 10. The sweat-glands ; 11. The hair; 12. The. nails. 

J. THE EPIDERMIS. 

The epidermis, cuticle, or scarf-skin is composed of layers of stratified epithelium- 
cells united together by a small amount of cement substance, and contains neither 
vessels nor nerves. Its upper surface is smooth, save for the markings above 







■r*jK ~ '*? 


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Fig. 1. — Epidermis, corium, and subcutaneous tissue: section of skin of negro. 
Photomicrograph, x 21. From the author's collection. 

mentioned; but its lower surface is studded with club-shaped processes that fit 
into the interpapillary spaces of the corium. It passes down into the hair-sacs, 
forming a portion of the root-sheaths, and it is continuous with the lining mem- 



ANATOMY OF THE SKIN. 15 

branes of the sweat and sebaceous glands. Its average diameter is from j4 to J^ 
mm. ; but it varies greatly, being especially thick on the palms and soles, and very 
thin on the lips and the genitals. It is being constantly desquamated ; and it is 
regenerated as constantly by the growth of new cells from the deeper strata of its 
own substance. 

It is composed of three layers, being, from without inward : 

1. The stratum corneum or horny layer. This is the outer protecting layer, 
and is formed of flattened, dried-out epithelial cells, structureless and without 
nuclei. The inner layers are somewhat rounder and more succulent, but the outer- 
most ones are merely dried scales. In the palms and soles the deepest cells of this 
layer appear brighter than the rest, and have been called the stratum lucidum 
(Oehl). 

2. The stratum granulosum or nuclear layer. This is composed of from two to 
five rows of granular refractive epithelial cells, with soft protoplasm and round 
nuclei. They owe their appearance to the numerous highly refractive granules that 
they contain, composed of a substance called keratohyalin by Waldeyer, which is 
of importance in the process of cornification. 

3. The rete Malpighii, rete mucosum, stratum spinosum, or prickle-cell layer, 
consisting of polygonal ceils joined to one another by fine hair-like protoplasmic 
processes. The upper rows of cells of this layer are flattened, but the lower ones 
are cylindrical, and rest upon the papilla; of the corium. 

2. THE CORIUM. 

The corium or true skin is the most important part of the cutaneous organ. It 
is composed of a dense network of interlaced connective-tissue fibers, together with 
others of the yellow elastic variety. Comparatively thin in children, in the adult it 
is 2 mm. or more in diameter ; but it varies much in thickness in different parts of 
the body. Exposure to the weather or other irritants causes increase of its volume, 
and in the negro race it is naturally of exceptional thickness. It contains vessels, 
nerves, lymphatics, and bundles of smooth muscular fibers, and it is penetrated by 
the hairs and their sheaths, and the ducts of the glands. We distinguish in the 
corium a papillary and a reticular layer. 

The papillary layer or papillary body is the outer portion of the corium, and 
lies in contact with the rete Malpighii of the epidermis. Its surface is closely 
studded with nipple-shaped projections or papillae. Upon these, and dipping down 
into the spaces between them, lie the cells of the lowest layer of the epidermis. 
The papillae themselves vary much in shape and size, but their average height is 
Y% mm. They are most marked on the palms and soles, but most abundant on the 
genitalia. They contain the blood- and lymph-vessels — the vascular papillae ; and 
the nerve-structures — the sensory papillae. 



l(i ILLUSTRATED SKIN DISEASES. 

The reticular layer lies under the papillary layer, is directly continuous with it, 
and is distinguishable from it only by the more regular arrangement of the connec- 
tive-tissue bundles of which it is formed. These are so interlaced as to form rhombic 
figures, the long axes of which usually run transversely to the axis of the part 
covered. Curling around the bundles are the yellow elastic fibers. The elasticity 
of the skin is due to this peculiar arrangement. The lowest fibers of this layer are 
directly continuous with the connective tissue of the subcutis. 

3. THE SUBCUTIS. 

The subcutaneous tissue lies under the corium, and is composed of connective 
tissue containing many elastic fibers and forming large loose meshes. Through 
this there run irregular bands and masses of more condensed connective tissue that 
unite the subcutis to the fasciae and other underlying tissues; and on the closeness 
of this connection depends the movability of the skin. Larger and smaller collec- 
tions of fat-cells are found in the meshes. The subcutis contains also large blood- 
vessels, lymphatics, nervous structures, sweat-glands, and the lower part of the 
deeper-seated hair-follicles. 

Where the fat in the meshes of the subcutis is collected in larger amount, the 
structure is known as the panniculus adiposus. This consists of masses of round or 
polyhedral fat-cells, closely packed in a connective-tissue network. It is most 
abundant in the skin of the palms and soles, the buttocks, and the female breast, 
but is absent in that of the ear and nose, where the skin is thin and fixed, and in 
that of the scrotum, where it is very muscular and movable. 

4. THE BLOOD-VESSELS. 

The epidermis has no blood-vessels, but in the corium and the subcutis they 
are very numerous. They form two distinct horizontally placed plexuses, one 
in the corium just beneath the papillary layer, and the other at the boundary line 
between corium and subcutis. This latter supplies the hair papillae, the sweat- 
glands, and the fat masses; the former sends branches to the papillae of the cutis. 
The veins follow the arteries, and form a similar plexus between the corium and 
the subcutis. 

5. THE LYMPHATICS. 

True lymphatic vessels are not common in the skin, though some are found in 
the papillae, and form a plexus at their base. The subcutis also contains some large 
lymph-vessels. Lymphatic spaces are, however, very numerous indeed; they form 
a dense network in the corium, especially in the neighborhood of the fat collections 
and the muscles. These spaces originate in the lower epithelial layers, beginning in 
the interspinal spaces between the prickle-cells. 



ANATOMY OF THE SKIN. 



6. THE MUSCLES. 

The intrinsic muscles of the skin are all of the smooth involuntary kind. There 
are two varieties of them : 

I. The arrectores pilorum. These are small bundles of smooth muscular fibers 
running diagonally from the connective tissue of the papillary bodies to the base of 




Fig. 2. — Arrector pilorum, hair-sacs, etc. : section of scalp. 
Photomicrograph, x 35. Fronvauthor's collection. • - 

the hair-sacs, to which they are attached by elastic threads. Their contraction erects 
the hair, empties the blood and lymphatic vessels, causes pallor of the skin, and finally 
expresses the contents of the sebaceous glands. Cilia and vibrissa? have no arrectores. 
2. Larger masses of smooth muscular fibers arranged in layers are found in 
certain places, notably in the skin of the scrotum, penis, around the mammilla, and in 
the eyelid. 

; ! 7. THE NERVES. 

The skin contains both medullated and non-medullated nerve-fibers. The 
medullated fibers are branches of the deeper subcutaneous nerves, and go to the 



18 



ILLUSTRATED SKIN DISEASES. 



Pacinian bodies, the tactile corpuscles, and the end-bulbs. The non-medullated 
fibers form a network in the papillary layer, and send up branches which form the 
subepithelial plexus ; from this there ascends a congeries of minute twigs that end 
in or among the prickle-cells of the rete. 

The Pacinian bodies or corpuscles of Vater are ellipsoid whitish bodies, 2-4 mm. 
in size, attached to the nerves like berries on their stems. They are found espe- 




Fk;. 3. — Pacinian corpuscles, lymph-spaces, panniculus adiposus, etc. : section of skin of finger-tip. 
Photomicrograph, x 21. From the author's collection. 

cially in the subcutis of the palms and soles, fingers and toes. A single medullated 
nerve enters each one at its lower extremity, looses its sheath, and passes to the center 
of the body as a naked axis-cylinder. In the upper part of the Pacinian body it ter- 
minates in an irregular enlargement or in pointed processes. Round this central fiber 
lies the core, composed of connective-tissue corpuscles ; and around this again is the 
thick capsular envelop that forms the mass of the Pacinian body. This latter 
consists of a number of layers of concentric fibers, each one composed of a hya- 
line elastic ground substance, connective-tissue fibers, and an inner layer of endo- 
thelial cells. 

The tactile corpuscles, known also as the corpuscles of Meissner or Wagner, are 



ANATOMY OF THE SKIN. 



19 



rounded or oval bodies, yV mm. in size, lying in the sensory papillae of the corium. 
They consist of a mass of connective tissue, round which there winds a medullated nerve ; 
the axis-cylinder enters the corpuscle and is lost. They are found in the regions where 
sensation is keenest, and especially in the skin of the last phalanges of the fingers. 




Fig. 4. — Pacinian corpuscles, nerve-trunks, artery, etc. : section of skin of finger-tip. 
Photomicrograph, x 35. From the author's collection. 

The end-bulbs of Krause are rounded bodies, consisting of a mass of cells 
in a delicate connective-tissue envelope. The nerve-fiber penetrates the bulb, 
and ends in one or more clubbed extremities. The end-bulbs are found more 
especially in the tongue, the lips and gums, the glans penis, and the clitoris. 



8. THE PIGMENT. 

Pigment is found in the adult only in the epidermis, its presence in the corium 
being always pathological. In the white races it is situated only in the deepest lay- 
ers of the rete Malpighii ; in the colored races it pervades all the cells up to the 
granular layer. It consists of granular pigment derived from the blood, and placed 
chiefly around the nuclei of the cells. It is more abundant in parts that are exposed 
to the light, in consequence of the action of the ultra-violet chemical rays. 



■20 



ILLUSTRATED SKIN DISEASES. 



9. THE SEBACEOUS GLANDS. 

These are small racemose glands, situated in the corium and subcutis, and 
generally connected with the hairs. From 2 to 6 mm. in size, a number of 
them are attached "to each hair, into the upper portion of whose sacs their ducts 
open. They are most abundant where the hair-follicles are most numerous, and 
they are absent where there are no hairs, as on the palms and soles and the glans 
penis. They are largest on the nose, scrotum, mons veneris, labia majora, and anus. 
They appear as appendages of the ordinary coarse hair; but the lanugo hair-sacs are 
apparently diverticula in the wall of the excretory duct of the sebaceous glands. 

They consist of a framework composed of connective tissue and containing the 
vessels, nerves, and lymphatics. This is lined with a large nucleated epithelium, 
which is prolonged into the excretory duct of the gland, being continuous with the 




Fig. j. — Sebaceous glands: section of skin of scalp. 

Photomicrograph, x 35. From the author's collection. 



external root-sheath of the hair, and therefore derived from the rete. Inside this 
lining membrane lies a mass of fatty epithelium-cells and detritus. 

The sebum is a semi-liquid oleaginous material, destined to lubricate the hairs. 



ANATOMY OF THE SKIN. 



21 



It consists of fifty per cent, of fatty matter, olein, cholesterin, etc., together with 

the remnants and detritus of the epithelium-cells. 

Certain special sebaceous glands are not connected with the hairs ; they are : 
I. The Meibomian glands, large glands situated at the free margin of the lids. 

2. Tyson's glands in the glans penis and prepuce. 3. The sebaceous glands of the 

labia minora. 

10. THE SWEAT-GLANDS. 

The sweat, sudoriparous, or coil glands are simple tubular glands coiled up into a 
ball, and situated deep in the reticular portion of the corium and in the subcutis 




t^ 






- 

7. 






ife3=;^ 



-Xm 









,-'■ & /: ' 




w&d 



' 



M 









&j? . y ■ 










V£j£l 




O? 




FlG. 6. — Sweat-glands and ducts : section of skin of palm. 
Photomicrograph, x 42. From the author's collection. 



22 ILLUSTRATED SKIN DISEASJ 5. 

They are small, round, yellow bodies }4~3 mm. in size, and are found everywhere 
save on the glans penis and the margins of the lips. They are most developed and 
abundant on the palms and soles, being sometimes large enough to be seen with the 
naked eye, and numbering between two and three thousand to the square inch. 
They are numerous and large also in the axilla and around the anus. Their total 
number is estimated at from two to three millions. Each tube, uncoiled, measures 
about 3 mm. in size. The coils end in excretory ducts that pass straight upward 
through the corium, and open at funnel-shaped depressions on the surface known 
as pores. 

Each coiled tube consists of a connective-tissue framework or membrana pro- 
pria, with some smooth muscular fibers, and lined with a cuboidal epithelium. The 
excretory duct is also lined with cuboidal epithelium ; it ends at the prickle-cell 
layer of the epidermis, and thence onward to the surface the duct is a simple cork- 
screw-like passageway, without special cellular lining. 

The secretion of the coil glands is partly sweat, and partly an oily material that 
serves to lubricate the skin. An abundant vascular supply surrounds each coil. 
The sweat itself is a watery fluid that differs somewhat in composition in different 
individuals and in different parts of the same body. It has a saline taste and an 
alkaline reaction. It is composed almost entirely of water, containing less than two 
per cent, of solid matter. This latter is mostly sodium and potassium salts, urea, 
neutral fats, and cholesterin. 

J J. THE HAIR. 

The hairs are columnar epithelial formations, the lower parts of which are 
embedded in the corium and subcutis, while the upper portions project upward 
through the epidermis and above the surface of the skin. They are found all over the 
body, except on the palms and soles, the vermilion border of the lips, the backs of 
the distal phalanges, the glans penis and the inner surface of the prepuce, the labia 
minora and the inner surface of the labia majora. We recognize two varieties : the 
true hairs, found on the scalp, eyebrows, eyelashes, beard, axillae, genitals, and the 
anus of the male ; and the lanugo hair, the soft down found on the face, the trunk, 
etc. ; they differ from one another only in point of size. 

Hairs are generally implanted obliquely in the skin in consequence of the 
arrangement of the connective-tissue bundles of the corium, in which their roots 
Ire ; but the hairs of the external auditory and the nasal passages, as well as those 
of the lips, are implanted straight. In certain races, as the Hottentots, for example, 
all the hairs have a straight implantation. 

Hairs are both elastic and strong, being capable of greta extension and able to 
bear heavy weights. They grow to a certain length, which varies with different 
individuals and is different in different locations, and then stop and fall out; the 



ANATOMY OF THE SKIN. 



23 



rate of growth being about half an inch a month. The life of an individual hair 
is from two to five years ; of an eyelash, one hundred to one hundred and fifty 
days. Warmth and frequent cutting promote their growth. They are among the 
most enduring portions of the body, as is shown by the well-preserved hair of many 
of the mummies. 




Fig. 7. — Hair and hair-follicle: section of skin of scalp. 
Photomicrograph, x 35. From the author's collection. 



We distinguish as belonging to the hair: i. A shaft, being that portion which 
projects above the surface of the skin; 2. A root, situated in the corium and the 
subcutaneous connective tissue, and ending in a knobbed extremity; 3. A follicle, 
being the involution of the dermic layers in which the hair is placed. 

1. The shaft or scapus is a long and usually straight column, tapering at its free 
extremity. It consists of a central portion, the medulla or marrow, composed of 
polyhedral cells containing fat and free pigment granules. It is often absent, 
especially at the extremities of the hair, and is not found in the lanugo hair. The 
mass of the hair, however, is made up of the cortical substance, consisting of elon- 
gated, flattened epithelial cells, arranged with their long axes parallel to the long 



24 



ILLUSTRATED SKIN DISEASES. 



axes of the hairs. These cells are more or less fused together, and contain gran- 
ular pigment. Outside of this is the cuticle, a delicate membrane investing the hair 
substance and binding its bundles closely together. It consists of flat, cornified 
epithelial cells without nuclei, overlapping one another like shingles on a roof. 




FlG. 8. — Hair-shaft and root. 
Photomicrograph, x 240. From the author's collection. 



2. The root or radix is thicker than the shaft, and ends in an expansion known 
as the hair-bulb. In the bottom of the bulb is a cup-shaped depression which rests 
upon the papilla at the base of the follicle. In its structure the root is essentially 



ANATOMY OF THE SKIN. 



25 



the same as the shaft; but the cortical substance is loose and spongy, and consists 
of cells closely resembling those of the rete mucosum. 

3. The follicle or hair-sac is a bag-like inversion of the corium. It is cylindri- 
cal, with a narrow mouth on the surface of the skin, and a larger rounded extremity 




Fig. 9. — Transverse section of hair and sac. 
Photomicrograph. From the author's collection. 

that lies in the corium or subcutis. It is essentially a continuation of the papillary 
layer of the corium. A little below the level of the corium is a constriction known 
as the neck, and here the ducts of the sebaceous glands open into the follicle. The 



26 



ILLUSTRATED SKIN DISEASES. 



follicles vary much in size in different localities, but in general they are from 2 to 6 
mm. in length. They consist of a connective tissue, in which several layers may 
be recognized. The external layers are similar to the loose connective tissue in 
which the sac is situated. The outermost layer is hyaline and transparent, and 
is known as the vitreous follicle-sheath. At the base of the follicle rises the papilla, 
a small club-shaped projection about fo mm. in size, which fits into the hollow at 
the bottom of the hair-bulb. It is simply a modified papilla of the corium, and it 
contains the vessels that nourish the hair, as well as non-medullated nerve-fibers. 
The growth and regeneration of the hair takes place from the papilla; new elements 
are formed there which elongate and move up, pushing the hair before them. New 
hairs grow from the old papillse when the former are pulled out or lost. 






Fig. io. 

Hair from head of female. 



Fig. ii. 

Cross-sections of hairs from head. 



Fig. 12. 

Hair from the head of a child. 



Fig. 13. 

Hair from the back of hand. 



Human hair magnified. (After J. F. Babcock.) 



Between the follicle and the root of the hair are two further coats, known as 
root-sheaths. The external root-sheath lies next to the vitreous follicle-sheath, and 
is a continuation of the general rete mucosum, consisting of the same stratified 
epithelial cells. The internal root-sheath lies inside the preceding, surrounding the 
root of the hair closely. It consists of cylindrical epithelial cells, and is divided 
into the sheath of Huxley and the sheath of Henle. 

The pigment of the hair depends on the color of the corneous cells of the corti- 
cal substance, and on the air the medulla contains. The basis color is blond to red ; 
pigment in granules and diffused gives the shades from brown to black. Soap, alkalis, 
and especially the peroxide of hydrogen destroy the pigment; the presence of much 
air in'the cortical substance renders the hair white. 

The cilia or lashes, the vibrissas of the nostrils, and the hairs of the external 



ANATOMY OF THE SKIN. 



27 



auditory passages differ from the ordinary true hairs in their implantation, which is 
straight, and in the fact that they have no arrector muscles connected with their 
sebaceous glands. Though they are thick hairs, they remain short. 

12. THE NAILS. 

The nails are epidermoidal structures found on the dorsal surfaces of the distal 
extremities of the fingers and toes. They form quadrilateral plates, curved slightly 
in their long diameters, and lying with their convex surface upward. Their anterior 
portion ends in a sharp border that overhangs the end of the last phalanx ; their 
posterior extremities and sides are embedded in a fold of skin. Their surface is 
smooth and glistening, and marked with longitudinal striae. They consist of corni- 
fied epithelial cells arranged in layers, similar to those of the ordinary epidermis, 
but fused more firmly together. This epithelium lies upon a corium that possesses 
certain peculiarities. Larger and smaller air- vesicles in the intercellular spaces and 
inside the lamellae cause the white spots so frequently observed in the nails. 




Fig. 14. — Transverse section of third phalanx. (After Toldt.) 
a, nail; i, epithelium of nail-bed; c, nail-bed; d, falx; e, bone of phalanx. 



The nail is divided into two distinct areas by a curved line near its posterior 
extremity, running parallel to the free border of the nail, and known as the lunula. 
The anterior area, of a pink color, rests upon the nail-bed, which is a corium cov- 
ered with a stratified epithelium, and represents the rete. This corium possesses no 
papillae, but its connective-tissue bundles are arranged in longitudinal bands con- 
taining the blood-vessels and the nerves. The ridges thus formed fit into corre- 
sponding depressions in the epithelium of the under surface of the nail itself. The 
posterior smaller portion is whiter, on account of the many light-refracting transi- 
tional epithelial cells that it contains. The corium under it is studded with papillae, 
like those of ordinary skin, and is known as the matrix. The posterior extremity 



28 



ILLUSTRATED SKIN DISEASES. 



of the nail is embedded in a fold of the skin, the nail-groove or falx. Here the 
stratum mucosum of the skin gradually passes into the epithelium of the matrix. 
At the lunula there is a decreased transparency of the nail, due to the presence of a 
broad layer of actively proliferating cells. 

The nail grows from the matrix, and its thickness is dependent on the breadth 
of that structure. The rate of growth is stated by Quain to be about 3 \, of an inch 
per week. The uppermost layers of the epithelial cells that compose it grow 
from the portion furthest back, while the lower cells are the product of the more 
anterior portion. Growth is continuous from behind forward. The nails are nour- 
ished from the subepithelial plexus of the corium of the bed, matrix, and nail-fold. 
They grow more rapidly in children than in adults, and in summer than in winter 
time. Under ordinary circumstances their growth is largely in excess of the wear 
to which they are subjected ; but there is a limit to it, and they cease to extend 
after a certain length is attained, ending in a narrowed, bent extremity. In some 
instances a length is attained of I x / 2 to 2 inches, and the nail is then crooked or 
curved upon itself. 



PHYSIOLOGY OF THE SKIN. 



The skin is an organ of great size and complexity, with functions of vital impor- 
tance in the body economy ; and any very extensive or permanent interference with 
them is deleterious to health, and may lead to death. The destruction of any very 
large portion of its area is fatal. The functions of the skin are varied, and are both 
general and special. General functions are its actions as a protecting envelop for 
the various other parts of the body, and its regulation of the body heat. Special 
functions are its activities as a breathing organ, as a secreting and excreting organ, 
and as an organ of sense. We shall consider them in their order. 

1. The skin as a protecting organ. The corium is elastic, from the large quantity 
of yellow elastic connective tissue that it contains, and, with the thick panniculus 
adiposus, protects the various organs of the body from the effects of external vio- 
lence. This protection is limited, however, and the skin can be ruptured by external 
pressure or traumatisms, or by internal distention, as in pregnancy, oedema, or tumors. 
Such ruptures tend to have a definite configuration, varying in different parts of the 
skin, and depending upon the general arrangement of the connective-tissue bundles 
of the corium. The epidermis itself is a bad conductor of heat, and protects the 
deeper parts in some measure from the effects of heat and cold. It also prevents 
the too free evaporation of fluids from the body. The cholesterin fats that are 
formed in the cornifying surface epithelial cells act as a check to progress of micro- 
bic life on the surface, since they do not, like the glycerin fats, form good culture 
media for them. 

2. The skin as a regulator of the body heat. The skin performs this function 
automatically, and by its means the body is enabled to withstand external tempera- 
tures that may vary rapidly and in fairly wide limits. When the temperature of the 
environment rises the muscles of the skin relax, the vessels of the papillary plexus 
become turgid with blood, and the surface becomes hot and red. Increased loss of 
heat by radiation occurs ; and the congestion of the vessels around the coil glands 
causes an increased production of sweat, the evaporation of which takes further heat 
from the skin. When the temperature falls the reverse occurs. The skin muscles 

29 



.'JO ILLUSTRATED SKIN DISEASES. 

contract under the influence of the cold, causing by the traction that they exert the 
erection of the obliquely implanted hairs, and giving rise to the condition known as 
goose-flesh or cutis anserina. The papillary vessels contract, the surface gets pale 
and cold, and the loss of heat by radiation and by the evaporation of sweat is 
reduced to a minimum 

3. The skin as a breathing organ. Respiration in its true sense is a function of 
the skin, oxygen being taken in and both carbonic acid and water being given off. 
The proportions of these substances are. however, very different from those of 
lung respiration. The oxygen absorbed is only y^y of that taken in by the lungs, 
and the carbonic acid excreted amounts to only one hundred and fifty grains in 
twenty-four hours; both are comparatively insignificant. But the water given off 
by the skin is twice as great as that excreted from the lungs, being some twenty 
ounces daily. It passes off mostly as a vapor of whose presence we are not 
cognizant, the insensible perspiration ; but under certain conditions its excretion is 
more rapid, and it accumulates in drops as the sensible perspiration or sweat. 
Muscular exercise, an external high temperature, the emotions, etc., increase the 
production of water ; the muscles of the skin relax, the vessels fill up, and the sweat 
pours out. 

4. The skin as a secreting organ. Both the sweat and the sebum are secretory 
products of the skin. 

The sweat is a clear, watery, saline fluid. It consists of from 97 to 99 5 per cent, 
of water, together with a small amount of ammonium chloride, ammonia, organic 
matters such as creatine, etc., and .04 per cent, of urea. Under certain pathological 
conditions, as in renal disease, this latter element may be increased so much as to 
be deposited in the form of crystals on the surface of the integument. The amount 
of solid matter in the perspiration depends, however, very much upon the amount 
of water that is ingested, and on the quantity of the secretion that is poured out. 
It is usually acid in reaction ; but it becomes neutral or even alkaline when produced 
in large quantities and for long periods of time. 

The sweat is a true secretion and is under direct nervous influence, as is shown 
by its well-known ready response to mental stimuli. There are special sweat-nerves, 
some coming from the spinal column, and others from the sympathetic, the centers 
that control the secretion being found in the cortex, the medulla oblongata, and the 
ganglia of the anterior cornua. The amount of the sweat varies greatly, and is 
dependent upon many different conditions ; but its average is one and three quarter 
pounds daily. It is increased by certain conditions, as decrease in the amount 
of the watery vapor of the atmosphere, warming of the body, muscular exercise, 
etc ; by direct nervous influence, as from mental emotions, and in certain nervous 
diseases; and by certain drugs, as pilocarpine and picrotoxin, which directly stimu- 
late the sweat-nerves. It is lessened by increase of watery vapor in the air, hinder- 
ing transudation ; by cooling the skin, causing contraction of the vessels, and dimin- 



PHYSIOLOGY OF THE SKIN. 31 

ishing tne arterial supply; by inflammations of the skin, when the sweat-nerves are 
paralyzed ; and by certain drugs that appear to act in the same way, as atropin 
and agaricin. 

The sweat is the chief product of the coil glands, but it is not their only one. 
They secrete in addition an oily material, the presence of which causes the odor the 
perspiration possesses and the staining of the linen that the sweat occasions. It has an 
important function in the lubrication of the skin ; for the sebaceous glands are appen- 
dages to the hair, and their secretion is destined mainly for them ; while portions of 
the integument that have no hairs, and consequently no sebum, as the palms and 
soles, are nevertheless well lubricated. This is also shown by the fact that animals 
that do not sweat have coil glands in their skins. 

The sebum is not a true secretion, for it is the product of epithelial proliferation 
and fatty degeneration in the sebaceous glands, and, moreover, is not under direct 
nervous influence. It does not, therefore, vary with external and internal conditions 
as the sweat does. It consists of fat in granules and drops, of fatt3^-degenerated 
cells and cell detritus, and of cholesterin crystals. It is evidently designed to lubri- 
cate the hairs, the glands that produce it being found only in connection with these 
bodies, and opening by their ducts into the hair-follicles. Its production is contin- 
uous, the sebaceous matter being gradually expressed by the action of the muscular 
structures of the skin upon the shaft of the growing hair. 

5. The skin as an excreting organ. Many substances, especially pathological 
ones and drugs, are extruded from the body with the sweat and the sebum. Urea 
is partly thus disposed of, especially when in excess, as are also iodine, bromine, 
etc., when taken internally. 

6. The skin as an absorbent organ. This function of the skin is an extremely 
important one from a therapeutic point of view, since all endermic medication de- 
pends upon it ; yet it can hardly be said that the integument is an active organ in 
this respect. The skin is certainly permeable to gases, and animals have been 
killed by keeping their bodies immersed in an atmosphere of sulphureted-hydrogen 
or carbonic-acid gas while their heads were free in the air. But water and watery 
solutions do not permeate the intact and fatty skin. The common idea that there 
is absorption of water or medicaments by the skin in the bath is an erroneous one. 
For the purpose of internal treatment medicated baths are quite useless. There is 
more water in the body after a bath, it is true; but this is simply because the body 
loses none of it while immersed. 

When, however, the surface fat of the skin has been to some extent carefully 
removed beforehand by the use of ether or chloroform, we may succeed in intro- 
ducing substances in watery solution into the body through the integument. More 
especially is this the case if the substance is used as a fine spray and for a long 
period of time. The constant current also enables us to introduce non-volatile sub- 
stances by cataphoresis into the skin ; this is markedly the case with the alkaloids 



iJ2 ILLUSTRATED SKIN DISEASES. 

strychnia, atropia, morphia, and cocaine, and the method may be used for local 
anaesthesia. In all these cases, however, the substance in question enters the skin 
through the ducts of the sebaceous glands; the epidermis resists all such attempts. 
It cannot be employed on the palms and soles, where these glands do not exist. 
Any break in the skin also permits absorption to be much more active. Under such 
circumstances many substances, such as salicylic acid, tincture of iodine, iodide of 
potash, etc., may be introduced into the system and demonstrated in the urine. 
Even salves and ointments are not absorbed by the unbroken skin, except in so far 
as they can be introduced into the sebaceous glands. 

7. The skin as an organ of sensation. The skin is the essential organ of ordinary 
sensation ; but the exact relationship of the tactile organs, the end-bulbs, Pacinian 
and tactile corpuscles to the various forms of the faculty is not known. It is well 
proven, however, that the parts most abundantly supplied with them and with 
nerve- fibers have the greatest sensibility. 

We distinguish in the skin the ordinary tactile or pressure sensibility, the tem- 
perature sensibility, and the sense of location. These different varieties of sensation 
have each their special nerves ; for it is certain that the kind of sensation experienced 
depends, not on the nature of the irritant that causes it, but on the nerve that is 
irritated. The same influence may cause different sensations in different parts of 
the body — warmth, cold, pain, or pressure; and after certain injuries to the nerve- 
centers, one kind of sensation, as that of temperature, may be lost in a part, while 
another, as that of ordinary touch, may remain. 

The ordinary tactile sensibility and its varieties, itching, tingling, formication, 
pain, etc., varies much in its acuteness in different parts of the body. Thus pin- 
points can be felt as double on the finger-tips at a distance of only 2—3 mm., on the 
back of the hands they must be 6 mm. apart, and on the skin of the back 6 cm. 
distant from one another. The sense of temperature, by which we distinguish the 
different degrees of heat and cold, and the sense of location, which enables us to 
refer a certain sensation to a certain portion of the body, also vary greatly in sharp- 
ness in different portions of the integument. 

SYMPTOMATOLOGY AND DIAGNOSIS. 

The symptoms of cutaneous disease are of varying origin and occur in manifold 
combinations. They vary in different individuals and in different stages in the same 
malady ; they are changed by treatment and obscured by accidental and non-essen- 
tial appearances. In comparatively few maladies is there a characteristic change, a 
pathognomonic skin symptom. Nevertheless the dermatologist has the great advan- 
tage of dealing with an organ that can be seen and felt, and of which, if necessary, 
microscopical examination can be made during life. 

The patient's family and personal history may throw important light on the 



THYSIOLOGV OF THE SKIN. 33 

origin and nature of his malady. So also may the history of the disease : the 
time that it has been present, as in lupus or syphilis ; the manner of its appear- 
ance, as in an urticaria or an ecthyma; its mode of progression, as in trichophytosis 
or epithelioma. But we must beware of placing too much reliance upon history. The 
patient's statements are erroneous as frequently from ignorance or forgetfulness as 
from intent. In the venereal maladies more especially the history is not only use- 
less, but misleading; and here we should avoid direct questioning, and rely rather 
upon the eruptions, anginas, abortions, etc. I do not hesitate to ssv that the diag- 
nosis of the syphilodermata is better made without the patient's assistance. 

The symptoms themselves are either subjective or objective. The farmer are of 
minor importance, and are often absent. They are either general symptoms, as 
malaise, fever, headache, chills, etc., or special ones, referred to the affected skin. 
There may be anaesthesia, as in lepra ; hyperaesthesia, as in the inflammatory dis- 
eases ; or, more commonly, some form of paraesthesia, described by the patient as 
itching, smarting, tingling, formication, a sensation of heat or cold, a sense of con- 
striction, or pain in various degrees. 

The objective symptoms are more numerous and important, and upon them the 
diagnosis must finally be made. They consist of the skin changes which the ex- 
aminer himself can appreciate. They are known as lesions, and their careful study 
is essential. And in order that the physician may not be misled, it is well to insist 
in every case upon an examination of the entire integument of the patient, as well 
as of the visible mucosae. 

Certain general conditions must first be mentioned. A symmetrical general 
eruption is usually due to internal causes; an unsymmetrical eruption is often the 
effect of external and local agents. If the covered parts only are involved, the 
clothing, or things that it contains, may be the cause of the disease. Excoriations 
and scratch-marks show the presence of pruritus, no matter what the patient's state- 
ments may be. Eruptions confined to the face, hands, and genitalia lead us to sus- 
pect the action of some external contagion, as that of poison-ivy or the itch-insect. 

The lesions themselves may be all of one kind or uniform, as in lichen planus, or 
they may be multiform, as in scabies. They may be discrete, as in acne, or confluent, 
as in some forms of variola. There is the greatest variety in their distribution. 
When there are many lesions over the whole body they usually follow the lines of 
cleavage of the corium, which O. Simon has so beautifully demonstrated, running in 
a general way from the spinal column parallel to the ribs, and in definite whorls and 
curves on the limbs and head. In other cases they follow the course of the nerve- 
trunks, as in zoster and leprosy. The configuration is also various, and a number 
of terms are employed to designate it. When the lesions are small and pinhead- 
sized they are called punctate ; when larger, like drops, they are guttate ; when the 
size of a coin, nummular; all of which occur in ordinary psoriasis. Again, the 
lesions may be circular or circinate, as in ringworm, or composed of annular con- 



34 ILLUSTRATED SKIN DISEASES. 

centric rings, as in herpes iris, or gyrate, as in some of the syphilodermata. They 
may be hypertrophic, projecting- above the surface of the skin, and perhaps exul- 
cerated, as in lupus. Sometimes they are dry, as in eczema squamosum, and some- 
times, as in eczema madidans, moist and weeping. In some maladies there is a def- 
inite locality of predilection, as in acne and lupus erythematosus for the face, and 
in erythema multiforme for the backs of the hands; in others, as in syphilis, the 
lesions may occur anywhere. Some are symmetrical, appearing on both sides of 
the trunk, or on both palms and soles; this is especially the case with the syphilo- 
dermata. Finally, as they vary much in color, sometimes in different stages of the 
same disease, a word descriptive of the color being often incorporated in the name, as 
is the case with lichen ruber and scarlatina. Many other qualifying terms are em- 
ployed, the consideration of which is not required here. 

The lesions found on the skin are either primary or secondary. The primary 
lesions are : 

1. Macules, fetches (Fr.), Flcckc (Ger.), circumscribed alterations in the color of 
the skin, without other change. They are usually rounded, but may be irregular in 
shape. Their color depends on their cause, but is most often red or brown or pur- 
plish. Some disappear on pressure; others do not. They may be due to: (a) 
Chemical agents, as in the stains caused by nitrate of silver. They are permanent, 
and do not disappear on pressure. (/;) Hyperemia, giving bright-red spots if arterial, 
as in roseola, and a purplish discoloration if venous, as in rosacea. They disappear 
when pressed upon, (<r) Pigmentary changes, as in vitiligo and chloasma, which are 
permanent, and are not changed by pressure. If the color is increased the spots show 
various shades of brown; if decreased they are white, (d) Extravasation of blood 
or blood coloring-matter into the skin. Macules of this kind are bright red at first, 
changing to purplish, brown, and yellow as they fade away. When the pigment is 
deposited in streaks they are called vibices ; if in spots they are called petechia ; 
while larger accumulations are known as ecchymoses or ecchymomata. (c) Perma- 
nent dilatation of the cutaneous vessels or the formation of new ones. Capillary 
naevi and telangiectases come under this heading. They are reddish or bluish, 
according to the variety of vessel chiefly involved, and do not disappear under pres- 
sure. The diffuse pigmentations of the skin which occur in Addison's disease, 
argyria, etc., do not belong to this category. 

2. Papules, papules (Fr.), Knotschen (Ger.), circumscribed projections from 
pinhead to pea size, containing no visible fluid. They are frequently aggregated in 
groups, as in syphilis. They may be seated in the corium or around the sebaceous 
glands or the hair- follicles. Their shape may be acuminate, rounded, flat-topped, 
or umbjlicated. Their color varies, being sometimes pale white or rosy, and at 
others violaceous or even blackish. They may remain papules throughout their 
existence, as in lichen planus; or they may become vesicles or pustules, as in variola ; 
or they may break down into ulcers, as in syphilis, or become enlarged into tuber- 



PHYSIOLOGY OF THE SKIN. 35 

cles, as in the same disease. They may itch severely, as in papular eczema, or they 
may cause no subjective symptoms at all, as in acne. They are due to : (a) cir- 
cumscribed plastic exudations in the skin (papular eczema) ; {b) collections of sebum 
in the glands (milium) ; (c) accumulations of epidermic scales around the hair-shafts, 
as in keratosis pilaris; (d) blood accumulations, as in purpura papulosa; (e) hyper- 
trophy of normal structures, as of the dermic papillae in warts; (f) circumscribed 
collections of new cells, as in lupus. They disappear finally by absorption, and often 
leave a macular stain behind. 

3. Tubercles, tubercules (Fr.), Kiiotcn (Ger.), are circumscribed projections of from 
pea to cherry size, containing no visible fluid. They may be considered as enlarged 
papules, but differ from the latter in being seated in the deeper corium and sub- 
cutis. They project to varying degrees above the surface, the greater part of their 
mass being often embedded in the skin. Their size and shape are very various ; they 
may be attached to the skin by a broad base, or be pedunculated. They are caused 
by: (a) circumscribed collections of new cells, as in lepra and cancer; (b) circum- 
scribed hypertrophy of a portion of the corium, as in fibroma molluscum. They 
end by absorption, or by breaking down and ulceration, and usually leave scars 
behind. 

4. Tumors, tinueurs (Fr.), GescJiwiilste, Knollen (Ger.), are masses of walnut size 
or over, situated in or under the skin. There is no limit to their size, and their shape 
and color are very variable. They may be fixed or movable, or they may be pedun- 
culated. Often they project above the surface, as in fibroma ; but sometimes, as 
in erythema nodosum, they are deep-seated. They are caused by : (ci) hypertrophy 
of existing elements of the skin and subcutis, as in warts and fatty tumors ; (b) collec- 
tions of new cells, as in epithelioma. They may remain stationary for long periods, 
or break down and ulcerate. 

5. Vesicles, ve'sicules (Fr.), Blaschen (Ger.), are circumscribed elevations of the 
corneous layer of the epidermis containing a clear fluid, and from pinhead to pea- 
sized. They may be rounded or acuminate, as in vesicular eczema, or umbilicated, 
as in variola. They originate in the deeper layers of the epidermis. They may be 
simple chambers, as in sudamina, or divided into compartments, as in varicella. 
They are usually short-lived, rupturing and spilling their contents on the surface of 
the skin ; but these latter may dry up or be absorbed. Again, they may go on to 
form pustules. They often occur in groups, as in zoster and herpes febrilis ; but 
they may be scattered over the body, as in varicella. They are generally accom- 
panied by burning or itching. 

6. Bullae or blebs, bulks (Fr.), Blasen (Ger.), are irregular elevations of the 
epidermis varying in size from that of a large pea to that of an egg, and containing 
clear serum, sero-pus, pus, or blood. They are formed, like the vesicles, in the 
deeper layers of the rete. They vary much in size, large and small ones being 
usually found together, as in pemphigus ; the smaller bullae are rounded or oval, 



36 ILLUSTRATED SKIN DISEASES. 

while the larger ones, often formed by the coalescence of several blebs, are irregular 
in shape. They are single-chambered, with strong walls that do not easily rupture ; 
their contents usually dry up, and they end by desiccation. There is no tendency 
to grouping, as with the vesicles. They occasionally occur in many of the acute 
inflammations of the skin, as urticaria and eczema; but they are commonest in 
pemphigus, herpes iris, erysipelas, scalds, and burns. 

7. Pustules, pustules (Fr.), Pusteln (Ger.), are circumscribed elevations of the 
epidermis containing pus, and varying in size from a pin-point to a filbert. They 
are really cutaneous abscesses, and always contain pus-cocci. They may originate 
as such; but usually, as in eczema, variola, etc., they begin as papules or vesicles. 
Their color is yellowish white, occasionally being darker or reddish when blood is 
mingled with their purulent contents. Being inflammatory products, they are 
always surrounded by a more or less extensive red areola of inflamed skin. Their 
shape may be acuminated or round, as in acne, or umbilicated, as in variola, or 
flattened and irregular, as in ecthyma. They usually rupture, their contents form- 
ing thick yellowish-brown or greenish crusts ; but they may also end by desiccation. 
Pain and tenderness are marked symptoms when the pustules are deep-seated. 
They may be superficial, as in impetigo, or the process may extend to the corium, as in 
ecthyma, or they may occur around the sebaceous glands, as in acne, or in connec- 
tion with the hair-follicles, as in sycosis. They are of common occurrence also in 
syphilis, scabies, and many dermatites. If the corium is involved they leave scars 
behind. 

8. Wheals, plaques ortiees (Fr.), Quaddeln (Ger.), are flat elevations of the integ- 
ument, from pinhead- to egg-sized, caused by a circumscribed oedema of the skin. 
They are due to a sudden outpouring of a thin serum from the papillary vessels, 
with subsequent vascular spasm ; when this latter relaxes the effused fluid is rapidly 
taken up again. The lesions are therefore very fugacious. Sometimes discrete, 
they usually coalesce into irregular plaques, as is seen in ordinary urticaria. Their 
color is reddish or whitish, dependent on the degree of vascular spasm, with a pink 
areola ; occasionally they are purplish in color, as in some forms of purpura. Some- 
times they are followed by discoloration of the skin, as in urticaria pigmentosa. The 
itching is intense and is a most marked subjective symptom ; occasionally there is 
burning or tingling. 

Secondary lesions occur in consequence of the existence of primary ones, or from 
other causes. They are : 

1. Excoriations or abrasions, excoriations (Fr.), HaiitabscJmrfungen (Ger.), losses 
of tissue of the skin due to mechanical causes. They vary much in size, shape, and 
extent. They occur most commonly in the itchy diseases, and are caused by the 
finger-nails. They are generally superficial lesions, the corneous layer of the epi- 
dermis only being removed and the mucous layer exposed. A thin serum is exuded, 
which dries up into brownish crusts ; and after these fall off a temporary discolora- 



PHYSIOLOGY OF THE SKIN. '6l 

tion of the skin is left. In rare cases the deeper layers of the epidermis or the corium 
itself is involved, and scars result. Excoriations usually occur in lines and streaks, 
which are studded with the minute bleeding points of the denuded dermic papillae. 
They are most commonly found in eczema, scabies, phtheiriasis, pruritus, etc. 

2. Scales, squdmes (Fr.), Schuppen (Ger.), are dry, laminated masses of epithelium, 
separated from the tissues below and sometimes mixed with sebum. Their size, 
shape, and quantity are very variable. They are usually dry, harsh, and brittle 
(eczema squamosum), their color is whitish or grayish, and they are often shiny. 
They may occur in large silvery lamellae (psoriasis), or in smaller plates (pityriasis), 
or as minute bran-like flakes (seborrhea). They are very common in the inflamma- 
tory diseases of the skin (scarlatina, erysipelas, eczema, etc.). The hyperemia and 
inflammation of the papillary layer cause an excessive production of epidermic cells, 
in which the normal process of cornification is replaced by a simple desiccation. 
They often occur with other lesions, as on the tops of papules and tubercles. 

3. Crusts or scabs, croutes (Fr.), Borken, Krusten (Ger.), are masses composed of 
dried exudation, or sometimes of a fungous growth. They vary much in size and 
shape, and may be adherent or loose. They are caused by : (a) Inflammatory 
exudations. If these be serum they are yellow and friable, as in eczema ; if it be pus 
they are darker and thicker (ecthyma) ; if mixed with blood they are reddish or 
blackish (pruritus), (b) Secretions, especially sebum, giving yellow, flat, adherent, 
and greasy crusts (seborrhea), (c) Fungi, causing yellowish or grayish crusts of 
varying shape (favus). The crusts of syphilis are dark brown or greenish in color, 
have a heaped-up, oyster-shell-like appearance, and are known as rupia. 

4. Fissures, fissures (Fr.), Rhagaden, HautscJirilndc (Ger.), are linear solutions of 
continuity of the skin. They usually involve only the derma, but occasionally they 
may extend into the corium. They may be dry or secreting or crusted. They 
occur as the result of motion in parts of the skin that have lost their elasticity, and 
more especially in the inflammatory diseases (eczema, syphilis, dermatitis). They 
are oftenest seen about the joints, upon the palms and soles, and around the mouth 
and anus. They are frequently very painful. 

5. Ulcers, ulceres (Fr.), Geschwiire (Ger.), are losses of substance of the skin in- 
volving the corium and caused by disease. They occur in a variety of maladies, as 
dermatitis, syphilis, lupus, leprosy, epithelioma, etc. They may be single or multi- 
ple, large or small, and rounded, kidney-shaped, or irregular; their edges may be 
sloping or undermined ; their bases may be dry or moist and covered with healthy 
granulations, or they may consist of necrotic tissue bathed in a foul discharge. These 
points are characteristic in the ulcers of many of the above maladies, and are of 
essential aid in their diagnosis. Ulcers are especially common on the lower extrem- 
ities on account of the frequency and persistence of dermatitis in that locality. They 
are sometimes entirely insensitive, but they may be very painful and tender. They 
frequently last for long periods of time, and they always leave a scar. 



38 ll.l.l STkATKD SKIN DISEASES. 

6. Cicatrices or scars, cicatrices (Fr.), Narben (Ger.), are connective-tissue new 
formations replacing dermal losses of substance in which the corium has been de- 
stroyed. From this latter condition it follows that papillae, hairs, and glands are 
absent in scars, though vessels and nerves remain, and the surface epithelium is 
present. They are of all sizes, shapes, and thicknesses ; they are raised or depressed, 
smooth or puckered. They are often very characteristic lesions, and they frequently 
enable us to diagnose the nature of past disease. The new connective tissue shrinks 
in the course of time, and the scar, at first soft and red, becomes harder, whiter, 
and glistening, and frequently causes deformity by the traction that it exerts on 
neighboring parts (ectropion). These changes are due in part to the gradual ex- 
pression of the blood by the contraction of the new growth, and in part to the de- 
struction of the mucous layer of the epidermis. Loss of tissue leading to scarring 
occurs in : {a) Ulceration ; this is the commonest cause, and is seen in many diseases 
(dermatitis, syphilis, wounds, burns), (b) Interstitial absorption, when the derma is 
infiltrated with new cells, and the normal elements are destroyed and absorbed, to 
be replaced by connective tissue (lupus, morphaea). (c) Pressure, causing absorp- 
tion and new connective-tissue formation ; this may be from within, as is seen in 
the lineae albicantes caused by distention (pregnancy, tumors), or from without, as 
by a parasitic growth (favus). There are usually no subjective symptoms, though 
scars are sometimes painful. 

7. Stains. These occur commonly after the various inflammatory diseases, and 
are caused by the blood coloring-matter that has escaped during the process. In 
many of them the redness is not marked, and passes off in a short time, as in erythema 
multiforme, psoriasis, etc. ; but in others it is darker and more persistent, as in 
syphilis and lichen planus. 

GENERAL ETIOLOGY. 

The causes of cutaneous diseases are very numerous, and only a cursory review 
of them can be given here. Many conditions, external and internal, may cause 
deviation from the normal. We may broadly divide skin diseases into those that 
are essentially symptomatic (scarlatina, measles), and those that are idiopathic and 
proper to the organ itself (keloid, verruca). 

Climate has a slight influence, some diseases occurring chiefly in tropical climates 
(leprosy, elephantiasis Arabum) ; season has more. Some maladies occur chiefly in 
hot weather (lichen tropicus, lentigo) ; others appear in spring and autumn (erythema 
multiforme, psoriasis) ; others, again, are worse in winter (eczema and other inflam- 
matory diseases). Occupation has a well-marked effect, as is shown by the "mortar 
eczemas " on the hands of masons, the callosities on the palms of laborers, and the 
dermatites of those employed in chemical factories and dye-works. Clothing, if of 
flannel, may excite pruritus, and the dyestuffs in it frequently set up eczemas. 



PHYSIOLOGY OF THE SKIN. 39 

Uncleanliness, strange to say, does not appear to be of much importance as an 
etiological factor in the production of skin disease, save in so far as it favors the 
persistence of the parasitic diseases (phtheiriasis, scabies, etc.), while the too frequent 
use of water and soap is of marked influence in keeping up catarrhal inflammation 
of the skin. 

Food is a factor of undoubted importance. It acts directly as an irritant if im- 
proper in quantity or quality, and indirectly by lowering nutrition, depressing cell 
vitality, and laying the tissues of the skin open to attack. Shell- fish, strawberries, 
etc., frequently cause urticarias, and in some individuals furunculosis is brought on 
by the ingestion of cheese. Drugs cause various eruptions, especially erythemas 
and urticarias ; iodine and bromine cause special forms of skin disease. Locally em- 
ployed, many medicinal substances, such as croton-oil, arnica, mustard, cause derma- 
tites. Contagion is responsible for many maladies of the integument, as is the case with 
animal and vegetable parasites in the exanthemata, syphilis, and malignant pustule. 

Race influences skin eruptions also. Negroes are prone to have keloid and 
leucoderma, and Jews are more frequently the victims of sarcoma cutis than others. 
Heredity is not so important a factor as is usually supposed, most of the instances 
that are cited being due to accident. The anatomical peculiarities of sex render 
males subject to sycosis barbae, while females alone suffer from Paget's disease. 
Apart from these, however, males have epithelioma oftener than females, while the 
reverse is the case with lupus erythematosus. 

Age is a factor also. Children have trichophytosis capitis and impetigo conta- 
giosa; ichthyosis generally shows itself by the end of the first year, and lupus vul- 
garis begins in early life. On the other hand, all the parasitic vegetable diseases are 
rare after the age of fifty, a time of life when carcinoma most commonly appears. 
At puberty the development of the glandular and hairy systems causes the es- 
pecial prevalence of certain cutaneous affections (comedo, seborrhea, acne vulgaris, 
which latter gets worse in women at the menstrual epoch). Chloasma and hydroa 
occur with especial frequency during pregnancy. 

Certain internal diseases have a marked effect on the cutaneous envelop. Diges- 
tive disturbances cause urticaria, rosacea, acne, and pruritus ; catarrhal jaundice and 
disease of the liver are often accompanied by pruritus and xanthoma ; and boils, 
carbuncle, and gangrene are frequently seen in Blight's disease and diabetes. 

GENERAL THERAPEUTICS. 

The rules of general therapeusis hold good in the maladies of the skin, and we 
need be no more afraid of curing a skin lesion too quickly, of " driving the disease 
in," than we are of stopping the inflammation in a joint or checking a gastro-enteri- 
tis too precipitately. The quickest cure with the least possible discomfort insures 
the most permanent result with the smallest amount of damage. The ideal thera- 



40 ILLUSTRATED SKIN DISEASES. 

peusis is of course the causative one ; but our present knowledge permits of its ap- 
plication in only a minority of cases. We are of necessity compelled to rely largely 
upon symptomatic treatment. Prophylaxis is as important here as elsewhere, and 
we are constantly called upon to protect the skin from chemical, mechanical, and 
microbic injuries. 

The intimate relationship between the integument and the system at large, and 
the frequent interdependence of morbid changes in the skin with those of internal 
organs, render it clear that a practical acquaintance with general medicine is an 
essential element in the successful treatment of diseases of the skin. Any attempt 
to separate the cutaneous envelop, pathologically or therapeutically, from the rest 
of the system, is foredoomed to the failure that awaits incomplete knowledge and 
empirical treatment. Hence treatment should be in most cases both constitutional 
and local ; and, whatever our opinions may be as to their relative importance in in- 
dividual diseases, neither can be neglected without detriment to the other. A well- 
balanced combination of both, based on a careful diagnosis both of the local skin 
lesions and of the underlying and concomitant body conditions, will give the best 
results. 

Almost all the drugs of the pharmacopoeia have been employed at one time or 
another in dermato-therapeutics, but the vast majority of them have been rightly 
abandoned. Recent years have seen many new remedies recommended, mostly the 
synthetic products of the laboratory. Of these also most have not withstood the 
test of time, but some valuable ones remain. New methods have been developed 
which have largely replaced the older ones, and for these we are indebted most 
largely and in the first place to Unna. But excessive richness of resource does not 
always mean greatest usefulness; and he who employs but a comparatively small 
number of methods and remedies will frequently be most successful in their use. 

GENERAL METHODS. 

These must necessarily depend very largely upon the general health and constitu- 
tional peculiarities of the patient. The appropriate treatment for each diseased con- 
dition of the internal organs must be employed, but their consideration belongs to 
the domain of general medicine. 

General hygiene is naturally of the greatest importance, for the nutrition of the 
skin is improved in the same way as is that of the internal organs. Washing and 
bathing are primary requisites; they stimulate the circulation of the skin, and re- 
move parasites and detritus. Exercise and change of climate are efficient aids to 
our efforts. Tonics — iron, cod-liver oil, quinine, and the simple bitters — must be 
used on general principles. 

Diet must not be neglected. Diseased conditions of the skin sympathize more 
closely than most others with gastro-intestinal disturbances, as I have shown above, 



PHYSIOLOGY OF THE SKIN. 41 

and much of our success or failure in their treatment will depend on attention to 
the food. It should be nutritious and bland; and condiments, salted and spiced 
foods, etc., should generally be avoided as indigestible. When there is abnormal 
action or disease of the alimentary tract the diet must be varied in accordance with 
the indications. Ales, wines, and liquors are in general bad ; but they may be used 
sparingly in those with weak digestions and in the old. A complete change of diet 
is often of great importance, especially in chronic eczema and psoriasis ; and I have 
sometimes found the latter disease rebellious in spite of all manner of treatment, 
until the patient was put on an absolute milk diet. 

Defective cutaneous action, as occurs in the inflammations, can frequently be 
aided by stimulating the kidneys by diuretics ; the acetate and citrate of potash, with 
buchu, digitalis, etc., may be frequently administered with benefit. 

Purgatives, saline and other, are of especial value in acne, pruritus, and urticaria, 
which are so frequently dependent on digestive disturbances. In almost every case 
of skin disease the regulation of the bowels is a necessity. 

Water is useful to cleanse the skin from foreign matter, living organisms, scales, 
and crusts. It is an irritant, and must be employed with caution in conditions of 
acute inflammation ; but it is often useful therapeutically in the chronic forms (chronic 
eczema, pruritus, psoriasis). It is employed as a general bath or as a lotion. 

Medicated baths : (a) Alkaline, usually of bicarbonate of soda or borax in the 
proportion of I to 200, are useful to remove crusts and scales, and in some subacute 
inflammations, {b) Sulphur baths, prepared by adding two to four ounces of sul- 
phide of potassium or an equal quantity of Vleminckx's solution (No. I, p. 43) to 
the water (scabies, etc.). (c) Starch and bran baths of varying strengths are useful 
in urticaria and other itchy eruptions. 

Lotions are often very efficient means of medicating the skin. They are : (a) 
Sedative, when opium, belladonna, glycerin, carbolic acid, boric acid, lead, etc., are 
added, and are useful in chronic inflammations (seborrheal eczema, acne vulgaris, 
rosacea) or as an antipruritic (pruritus, urticaria), (b) Stimulating, with alcohol, 
corrosive sublimate, tar, and various acids and alkalis (chronic eczema, etc.). {c) 
Astringent, when prepared with tannin and lead (hyperidrosis). 

Glycerin does not penetrate the skin and therefore should not be employed 
where more than a superficial effect is required. It is irritant when pure, even 
when free from formic and butyric acids ; but when diluted with water it is rather 
sedative. With starch glycerin forms a series of pasty semisolids known as glycer- 
ols ; their action is mainly protective. Perhaps the commonest is the glycerol of 
lead. 

Alcohol, ether, and chloroform, when applied pure, take water and fat from the 
skin, and render it dry and scaly. Their use thus promotes the absorption of watery 
fluids and fats. Ethereal solutions of drugs, employed as sprays, are useful, cheap, 
and often very effective. 



4l> illustrated skin diseases. 

Kerosene and benzin are employed to destroy vermin. They must be used with 
caution on account of their inflammability. 

Oils are either bland, as olive-oil, sweet-almond oil, castor- and cod-liver oils, 
or stimulating, as the oils derived from tar, the oils of cade, birch, juniper, etc. 
They are employed to soften crusts and facilitate their removal, to protect inflamed 
dermal surfaces, and to replace the natural fatty matters of the skin and hair. For 
the first purpose olive-oil and oil of sweet almonds are the best (pityriasis rubra, 
pustular eczema, psoriasis) ; linseed-oil is the favorite for protective purposes (burns) ; 
cod-liver oil is employed externally and internally in the tubercular skin diseases 
with excellent effect ; and castor-oil is frequently added in the proportion of i to 
10 per cent, to various spirituous lotions. The oils also enter into the composition 
of many of the ointments. 

Fats are employed to soften crusts, to replace the natural fatty matters, and as 
bases for ointments. Some are waxy and hard; others, containing more olein, are 
soft and butter-like. The chief varieties are: (a) Adeps suillis, or lard, best em- 
ployed, with the addition of 4 per cent, of benzoic acid to prevent decomposition, as 
benzoated lard. This is a glycerin fat, and has been the one in common use; but 
it is fast being displaced by (b) adeps lanae (lanolin), a cholesterin fat extracted 
from lamb's- wool. This is sterile and does not become rancid ; it enters the skin 
more readily than do the ordinary glycerin fats, and, most important of all, it is 
readily miscible with water. Being very tenacious, it requires the addition of a 
small quantity of olive-oil or glycerin. It is undoubtedly the best general ointment 
basis that we possess, more especially in cases where deep penetration into the skin 
is required (ringworm, psoriasis, syphilis inunctions), (c) Suet, used chiefly in the 
preparation of Unna's salve- muslins, {d) Marrow fat, employed for pomades and 
cosmetics. Cocoa-butter, spermaceti, white wax, and paraffin are also used. 

Vaseline and cosmoline are not fats, but petroleum products. They have been 
extensively used as ointment bases, and are valuable when applications are to be 
made to the hairy parts, where lard or adeps lanae are too glutinous. They irritate 
the skin, however, and Shoemaker has shown that their penetrating power is far in- 
ferior to that of the other bases. 

Ointments are the oldest, commonest, and in most cases still the best form in 
which to apply local remedies to the integument. They are made of the various 
fats above mentioned, mixed with different medicinal substances. They are : (a) Seda- 
tive, protecting inflamed parts from the air, moisture, etc. (acute eczema, derma- 
titis) ; cold cream and simple ointment are examples, (b) Astringent, containing 
zi:ic oxide, lead acetate or oleate, boracic acid (subacute eczema, etc.) (c) Antiseptic, 
with iodoform, salicylic, boracic, or carbolic acids or ammoniated mercury. These 
are employed in the pustular skin diseases (impetigo contagiosa, eczema pustulosum). 
(</) Stimulating, and containing tar, oil of cade, carbolic acid, naphthol, chrysarobin, 
pyrogallol, salicylic acid, sulphur, mercury salts, etc. (chronic inflammations, psoria- 



PHYSIOLOGY OF THE SKIN. 43 

sis, lichen planus, prurigo). In all cases they have a deeper and more permanent 
effect when spread upon muslin and bound on the part than when they are simply 
rubbed in. 

Pastes are very efficient applications, being practically salves made stiffer by the 
addition of various powders ; they may often be substituted for these latter with ad- 
vantage. They form better protectives, since they adhere more closely to the skin 
and exercise some pressure upon it. They soon -dry, and their porosity permits the 
free escape of the dermal secretions. Lassar has given us the formula for one of 
the first ones, which is known by his name, and is one of the commonest and most 
useful (No. 2, p. 43). The gum arabic paste of Unna is also widely employed (No. 3, 
p. 43). Various substances may be incorporated with these pastes, the special for- 
mulas for which will be given when we consider the treatment of the diseases in 
which they are used. 

No. J, Vleminckx 's Solution. No. 2. Lassar 's Paste. 

ft Calcis ..... 1 part ft Acid, salicyl. ... 1 part 

Sulphur, sublim. ... 2 parts Zinci oxidi 

Aq. dest. . . . 20 " Amyli .... aa. 12 parts 

Coque ad fvi ; deinde filtra. Adip. lanse ... 24 " 

No. 3. Gum Arabic Paste. No. 4. Glyco-gelatin. 

ft Mucilag. gum. acac. R Zinci oxidi ... 40 parts 

Glycerini . . . aa. 20 parts Gelat. alb. 

Pulv. (zinci oxidi or ac. Glycerini . . . aa. 25 " 

salicyl.) ... 40 " Aq. dest. . . . no " 

No. 5. Hebrals Green Soap Tincture. 

R Sapon. virid. .... 8 parts 

Spirit, vini rect. . . . . 4 " 

Solve, filtra, et adde 

Spirit, lavandulas . 1 part 

Plasters are employed where a continuous and deep-seated action is required. 
Lead-plaster, being less irritating than that made with resin, is to be preferred for 
use on the skin. By this means the various drugs can be applied to the skin. Bet- 
ter, however, and more extensively used, are certain recent modifications. These 
are : [a) Salve-muslins, which we owe to Unna, and which are ointments already 
spread upon unbleached muslin. They are made by drawing the muslin through 
the liquid ointment mass, and, being non-adhesive and coated on both sides, they 
need the protection and support of an external bandage. They are comfortable, 
elegant, and very adaptable. All the ordinary ointments can be procured in this 
form, those most commonly employed being the zinc, salicylic acid, diachylon, and 



44 ILLUSTRATED SKIN DISEASES. 

mercurial muslins. Still more desirable than these are the two following prepara- 
tions, devised respectively by Unna and H. von' Hebra. (&) Plaster-muslins, which 
are ointments on an impermeable gutta-percha base, and spread only on one side. 
As they all contain the oleate of alum they are adhesive of themselves, and hence 
require no external dressing for protection and support. Arsenious, boric, and car- 
bolic acids, chrysarobin, pyrogallol, iodoform, and all the other drugs that are em- 
ployed in dermato-therapeutics are now prepared in this form, which is very con- 
venient and cleanly. It is a specially desirable mode of application where a deep- 
seated action is required, or when a complicated area, as the lobe of the ear, is to 
be treated, (c) Collemplastra, made of rubber and adeps lanas with the admixture 
of various drugs, and spread on muslin, are as convenient as the plaster-muslins, 
and are much employed. 

The glyco-gelatins are important preparations that we owe to Pick and Unna. 
They dry up into protecting skins, and, with varying proportions of tar, resorcin, 
sulphur, chrysarobin, and other drugs, are extremely valuable in the localized der- 
matoses (dermatitis, eczema, pruritus). Dabbing the surface with absorbent cotton 
and applying a bandage before the gelatin has hardened increases their thickness 
and protecting power. They hinder scratching, keep away external irritants, and 
sustain the parts. Unna's formula (No. 4, p. 43) is good, but the proportion of the 
various ingredients must be varied with the season of the year and the amount of 
other fluid or solid ingredients that are added. 

Traumaticin, a 10-per-cent. solution of gutta-percha in chloroform, and flexible 
collodion are occasionally employed in circumscribed dermatoses. Chrysarobin, 
iodoform, zinc oxide, salicylic acid, etc., may be thus applied (chilblains, corns, 
rhagades, ringworm, and lupus erythematosus). 

Salve-pencils are crayons of wax and oil in which are incorporated various drugs 
— carbolic acid, chrysarobin, ichthyol, corrosive sublimate, etc. They may be em- 
ployed for very small disease areas (psoriasis, eczema seborrheicum). Paste-pencils 
contain no fat, being made of starch and gum. Arsenious acid, corrosive sublimate, 
iodoform, cocaine, etc., may be thus applied to limited surfaces of skin. They are 
especially valuable in that they can be used on denuded areas and on mucous 
membranes (chancre, chancroid, condylomata, lupus). 

Soaps are combinations of the fatty acids and alkalis, sodium forming the hard 
and potash the soft varieties of the article. They are used to cleanse the skin of dirt 
and crusts, to remove the corneous layer of the epidermis, and as a menstruum for 
various medicinal substances. They are cleanly, energetic, and cheap; and the per- 
fection that has been attained in their manufacture has led to their employment in 
a large variety of dermatoses. The surface may be simply washed with them, or 
the lather may be allowed to dry in situ ; but when a more deep-seated action is 
desired, the soaped part may be covered with a layer of rubber tissue. The alka- 
line soaps are employed to deprive the integument of its fat, and to soften and re- 



THYSIOLOGY OF THE SKIN. 45 

move the upper epidermic layers (psoriasis, ichthyosis). They are very irritant, 
however, and cannot be employed in inflammatory conditions. The most useful o) 
these is the sapo viridis or green soap, which may be used either pure or in an alco- 
holic solution, as recommended by Hebra (No. 5, p. 43). The best skin soaps, how- 
ever, must be either neutral or contain an excess of fatty material, like the so-called 
superfatted soaps of Unna. Many varieties are manufactured, the most useful being 
those containing mercury, tar, sulphur, ichthyol, resorcin, creolin, and iodoform 
(syphilis, chronic eczema, scabies, rosacea, etc.). The marble and sand soaps are 
employed where a rapid removal of the superficial epidermic layers is desired 
(comedo, acne). 

Powders are used to protect the skin and to absorb secretions. Starch and tal- 
cum are those most commonly employed. They may be dusted or insufflated over 
the affected parts, or applied inclosed in linen bags. Various medicinal powders, 
as calomel, aristol, iodoform, are also used. 

Caustics are extensively employed in certain diseases. Caustic potash is effec- 
tive but very diffusible, and must be used with caution ; arsenious acid is excellent, 
apparently picking out the diseased tissues, but must not be used over a large area 
or near the mucous orifices, as it is liable to be absorbed (neoplasmata, especially 
epithelioma, lupus, warts). Chloride of zinc is slow and painful, but appropriate in 
certain cases. Chromic acid and the acid nitrate of mercury are also used (chan- 
croid). 

Parasiticides are very numerous. Sulphur, naphthol, and balsam of Peru are 
used in scabies; corrosive sublimate, ammoniated mercury, and mercurial ointment 
in pediculosis. Chrysophanic acid is an excellent vegetable parasiticide (trichophy- 
tosis, favus). 

Of the bactericides one of the most important is iodoform, from its action on 
the pus-cocci and the tubercle-bacilli. Its odor and the possible dangers of absorp- 
tion are against it. Aristol and iodol are fairly good substitutes. Pyoctanin has 
given good results in epithelioma ; but the staining that it causes prevents its exten- 
sive use in dermatology. 

SPECIAL REMEDIES. 

Arsenic is no panacea for diseases of the skin ; it is useful in but few affections 
and harmful in many. It acts directly upon the mucous layer of the epidermis, and 
is employed in chronic scaly diseases and some others (psoriasis, chronic eczema, 
lichen planus, pemphigus, hydroa). In the inflammatory diseases, during their acute 
and subacute stages, it does no good at all ; in fact, it increases the gastro-intestinal 
irritation upon which many of them depend. It should be given always after eating. 
Fowler's solution is usually employed, the dose being three drops in the beginning, 
gradually increased to ten or fifteen, in accordance with the patient's tolerance of 
the drug. Arsenious acid in tablet form, or combined with black pepper in the cele- 



4() ILLUSTRATED SKIN DISEASES. 

brated Asiatic pill (No. 6, p. 46), is also an excellent form for its administration. Where 
the employment of mercury is also indicated, Donovan's solution, the liquor arsenici 
et hydrargyri iodidi, may be used. It must not be forgotten, however, that a spe- 
cial idiosyncrasy for arsenic exists in some cases, and we must be on the lookout for 
the first symptoms of poisoning — the puffy eyelids, the irritated conjunctivae, and 
the coryza. It occasionally causes a general exanthem. Arsenic is also employed 
externally (epithelioma, rodent ulcer), in the form of Marsden's paste (No. 7, p. 46). 



No. 6. Asiatic Fill. 






No. 7. Marsden's Paste. 




fy Ac. arseniosi . 


. gr. Ixvi 


& 


Ac. arseniosi 




Pulv. pip. nig. 


. 3ix 




Pulv. gum. acac. 


aa. p. e. 


Gum. acac. 






Aq. q. s. ut ft. pasta. 




Aq . . . . 


. aa. q. s. 








Div. in pil. No. 800. 






No. 9. Calomel Suspension. 




No. 8. Utigt. Chrysarobini 


Co. 


# 


Calomelani .... 


1 part 


Yji Chrysarobin . 


5 parts 




Albolene .... 


10 parts 


Salicylic acid 


2 « 




ui 10 = 1 grain. 




Ichthyol . 


5 " 








Vaseline . 


88 " 









Tar is a very efficient topical application in many of the more chronic skin dis- 
eases (eczema, psoriasis). It lessens hyperemia, infiltration, discharge, and scaling, 
and is an efficient antipruritic. Combined with sulphur, as in Wilkinson's ointment 
(No. 38, p. 81), it is especially good ; but it is liable to cause local irritation (acne) or 
systemic irritation if used too strong or in too large quantity. Pix liquida or oleum 
picis may be employed ; but oleum cadini or oleum rusci is usually to be preferred. 
They may be used pure, with the addition of a little ether, as a tincture, or in a 10- 
per-cent. ointment (subacute and chronic inflammations, psoriasis, parasitic diseases, 
and pruriginous diseases). In acute inflammations, as eczema madidans, they can- 
not be used. The oil of lavender will mask the odor of the drug. 

Ichthyol is the common name of the sulph-ichthyolate of ammonium, and is a 
tarry liquid, the distillation product of a fossil bitumen found in the Tyrol and in- 
troduced into dermato-therapeutics by P. G. Unna. It has been used internally 
with much success, in pills of from one to five grains, to reduce the hyperemias of 
the erythematous diseases (rosacea, lupus erythematosus). In weak concentrations, 
1 to 4 per cent., it is keratoplastic, stimulating proliferation of the corneous layer 
(intertrigo, acute eczema) ; in the proportions of 10 to 20 per cent, it is keratolytic, 
destroying the horny layer and acting as a vasoconstringent, antiseborrheic, and 
antiparasitic agent (chronic eczema, dermatitis, pruritus, acne, rosacea, etc.). Nuss- 
baum first recommended its use in erysipelas, which has become almost universal ; 
20- to 50-per-cent. ointments are proper. It may be applied as a salve, a paste, a 
solution, or a soap. 



PHYSIOLOGY OF THE SKIN. 47 

Thiol is employed as a substitute for ichthyol, and, like it, contains a large pro- 
portion of sulphur. It is less irritating and odorless, but also less active. It comes 
in both liquid and powder form, and the indications for its use are the same as those 
for ichthyol (burns, acne, rosacea, zoster). 

Resorcin, like ichthyol, is keratoplastic and keratolytic in solutions of different 
strengths. Care must be taken to prescribe always the pure white " albissimum " 
variety. It is a valuable antipruritic, antiseborrheic, and antiparasitic (seborrhea 
capitis, pruritus, scabies), being employed in I- to 5-per-cent. solution or ointment. 
It has been used as a 25- to 50-per-cent. paste or plaster in the treatment of super- 
ficial epitheliomata. 

Sulphur is perhaps our standard parasiticide (scabies, tinea versicolor). It is also 
employed in acne, comedo, seborrhea, and the other affections of the sebaceous 
glands. 

Naphthol, a coal-tar phenol, is frequently employed as a substitute for sulphur 
in the parasitic diseases. It is also used in the chronic inflammations of the skin, 
especially in psoriasis. 

Chrysarobin is a very efficient stimulant to the skin, causing a dermatitis accom- 
panied by a peculiar brownish- red to purplish staining of the skin. Patients should 
be warned that it ruins the clothing, and it should never be employed about the 
face on account .of the very intense conjunctivitis that it sets up if conveyed to 
the eyes. In 5- to 1 5-per-cent. ointment, plaster, or collodion it is an extremely 
useful agent in psoriasis and chronic eczema. It is valuable also in favus and 
trichophytosis capitis. Unna's compound chrysarobin ointment is useful (No. 8, 
p. 46). 

Anthrarobin, produced from alizarin, has been used as a substitute for chrysaro- 
bin, the indications and dosage being the same. It does not inflame the skin nor 
stain the clothing, but it is a far less active agent. 

Iodoform finds its chief application in chancre, chancroid, and the ulcerative 
syphilodermata. Aristol, which is odorless, may be used in its place, but cannot re- 
place it. The same may be said of dermatol or the subgallate of bismuth, a yellow, 
insoluble, and odorless powder. It is, however, of value in the acute dermatites. 

Pyrogallol is, next to chrysarobin, our most valuable topical agent in the treat- 
ment of psoriasis. It must be used in weak concentration, and over not too large 
an area, as systemic absorption and poisoning are liable to occur. In 50-per-cent. 
plaster it is employed in carcinoma of the skin, where it acts radically, destroying 
the affected area. It is slow, but comparatively painless. 

Salicylic acid occupies a peculiar place in dermato-therapeutics. It is a slow 
solvent of the epidermis, loosening it and separating it from the corium beneath 
without inflammation. It is employed in 10- to 25-per-cent. ointment, collodion, 
or plaster (callositas, clavus, etc.). In weaker strengths (1 to 5 per cent.) it is a ker- 
atoplastic agent, and may be used in the acute dermatoses (eczema vesiculosum). 



18 ILLUSTRATED SKIN DISEASES. 

Menthol is an excellent antipruritic, and may be employed in 5- to 10-per-cent. 
ointment or solution. 

The preeminent value of mercury in the syphilodermata is well known. It may 
be introduced into the body in three chief ways. That by the mouth is the oldest, 
and is still in many cases the most convenient method. The proto-iodide is the 
preparation most commonly used, and it fills all the indications and has as few draw- 
backs as any of the others. While ptyalism and general mercurial intoxication do 
not readily occur, the gastro-intestinal tract is very liable to be irritated. The bi- 
chloride also is liable to disagree. Of the multitude of other preparations that have 
been employed, only the tannate, introduced by Lustgarten, deserves mention here. It 
causes less irritation than any of the others, can be given in larger doses, and is espe- 
cially useful in the treatment of children. The cutaneous method, or that of inunc- 
tion, is a very efficient way of introducing mercury into the system, and is still the 
favorite one with many authorities. The metal enters the deeper layers of the skin 
through the glandular openings to some extent, but it is certain that a large part of 
its efficacy is due to the inhalation and absorption through the lungs of the mer- 
curial vapors given off during the process. Mercurial ointment, the oleate of mer- 
cury, and mercurial soap have their advocates. The method is one that requires 
considerable labor and patience. Stomatitis is apt to occur, and the mouth and teeth 
must be carefully watched. Mercurial eczemas and erythemas are also seen, but the 
gastro-intestinal tract escapes. 

The subcutaneous or hypodermatic method we owe to Lewin, and its introduc- 
tion was certainly an important advance in the treatment of the syphilitic diseases. 
Either the soluble or the insoluble salts may be employed. The sublimate still re- 
mains the best of the soluble salts, and is generally preferred to the albuminate of 
Bamberger and the formidate of Liebreich, etc. They all cause a considerable amount 
of pain, and the injections must be frequently repeated. The insoluble salts, and 
especially calomel (Xo. 9, p. 46), first used by Scarenzio, are very effective, and I 
consider their introduction into the subcutaneous and muscular tissues the best 
method in our possession for the treatment of luetic disease. Suspended in albo- 
lene or fluid cosmoline it can be given in doses up to 1 ]/ 2 grains. The abscesses so 
frequently observed at first are of rare occurrence now that antiseptic precautions 
are regularly employed. The pain occasioned is moderate, and the resultant infil- 
trations usually cause but little inconvenience. Silva Arauja employs the salicylate, 
while Lang and Neisser prefer the so-called gray oil, composed of mercurial oint- 
ment thinned with oil. Erythemas, etc., and general intoxications are rare with 
this method, and the gastro-intestinal tract is unaffected. 

Iodine and its compounds are also more especially used in the syphilitic skin 
diseases. The potassium, sodium, and ammonium salts and iodoform are those 
chiefly employed. In the non-syphilitic diseases their use is limited. They do 



PHYSIOLOGY OF THE SKIN. 49 

some good in scrofuloderma, lupus, keloid, but they are themselves not infrequently 
the cause of acneform, purpuric, and bullous eruptions. 

Quinine is of value in many diseases, more especially in the neuroses (pruritus, 
chronic urticaria) and in maladies accompanied by malarial symptoms. It some- 
times causes a general exanthem. 

Iron is indicated in the diseases accompanied by anemia and chlorosis, as is fre- 
quently the case with acne and eczema. Cod- liver oil is very useful as a general 
skin tonic, and was highly esteemed by the elder Hebra on that account. It may 
be employed in scrofuloderma, lupus, tuberculosis cutis, scleroderma, chronic ec- 
zema, and syphilis, and is of especial value in children. 

Ergot is of some use in acne, purpura, etc., probably on account of its action 
upon the unstriped muscular fibers of the skin and the uterus. 

Electrolysis is an agent of great value in the treatment of certain affections of 
the skin (hirsuties, warts, naevi). 

The instruments required are a galvanic battery, a milliampere-meter, forceps, 
needles, and holder. Of these latter I have found the one shown in Fig. 1 7 most 
convenient. Fine irido-platinum needles may be employed, but the ordinary 
broaches used by watchmakers are much cheaper and just as good. The amount 
of current that can be borne varies from 2 to 10 milliamperes, depending on the 
sensitiveness of the patient and the part that is treated. The needle is attached to 
the negative pole of the battery, and a suitable sponge-holder to the positive one. 
The hair to be removed is grasped with the epilating forceps, care being taken that 
no traction is made upon it. The needle is then carefully passed into the follicle 
along the side of the hair-shaft, and the skin, if possible, is not to be pierced. The 
depth to which the broach is introduced varies from 2 to 6 lines, dependent on the 
depth of implantation of the hair. The circuit is then completed by the patient 
pressing the sponge-holder against his hand or some portion of his body. In a few 
moments a fine foam appears around the needle, and the electrolytic action has 
commenced. . It is allowed to go on until the hair is loosened in its sheath and 
comes away without traction by the forceps. The sponge-electrode is then removed 
and the needle withdrawn. Care must be taken to introduce the needle before, and 
remove it only after, the circuit is broken, so as to avoid giving the patient "a shock. 
From 10 to 50 hairs can be readily removed at a sitting. The success of the opera- 
tion depends on the electrolytic destruction of the papilla of the hair. This will not 
always be effected, and we must expect 10 to 25 per cent, of the hairs that are 
treated to grow again. 

Certain instruments other than the ordinary surgical ones are daily used by the 
dermatologist. Sharp dermal curettes of various sizes, and fenestrated to allow the 
escape of collected material, are employed for erosion of the surface (acne, epitheli- 
oma). Epilating forceps for the removal of hairs (perifolliculitis, trichophytosis) 
should have broad, flat blades and easy springs. Spoon-shaped comedo extractors, 



50 



ILLUSTRATED SKIN DISEASES. 



the plugs being expressed by lateral pressure, are far preferable to the old-fashioned 
watch-key kind. Grappling forceps are useful to seize small portions of tissue, 
tumors, etc., that are to be ablated. Keyes's cutaneous punch is employed to re- 
move small circular areas of skin (nasvi, powder grains). Linear scarification is done 



Fig. 15. 

Scarificator. 



Fig. 16. 

Comedo extractor. 



Fig. 17. - 

Xeedle and holder 

for electrolysis. 



Fig. 18. 



Fig. 19. 

Dermal curettes. 




Fig. 20. 



with the cutisector (rosacea). A glass pleximeter is useful to express the blood 
from the skin, rendering new growths therein more visible (lupus vulgaris). Dental 
burs are employed to destroy localized new growths (lupus nodules). A small 
spear-shaped spud is useful for opening acne pustules, small dermic abscesses, etc. 
(See Figs. 15-28, pp. 50, 51). 



PHYSIOLOGY OF THE SKIN. 



51 




Fig. 2i. 

Grappling forceps. 



Fig. 22. 

Epilating 
forceps. 



Fig. 23. 



Fig. 24. 



Spear-shaped spud. Keyes's cutaneous 
punch. 



Figs. 25, 26, 27, 28. 
Dental burs. 



CLASSIFICATION. 






OUR knowledge of the etiology and pathology of cutaneous diseases is still too 
incomplete to permit of a perfect classification. Yet an imperfect one is better than 
none at all, for it groups the various maladies according to relationship of some kind, 
and enables us to take a general survey of the ground to be traversed. The classi- 
fication of Jessner, slightly modified, is perhaps the most useful. 

Class I. Functional Disorders. 
i. Sensory: Bromidrosis, 

Pruritus. Chromidrosis, 

2. Motor: Uridrosis. 

Dermatospasmus. (b) Of the sebaceous glands: 

3. Secretory ; Seborrhea, 
(a) Of the sweat-glands : Comedo, 

Hyperidrosis, Milium, 

Sudamina, Steatoma, 

Anidrosis, Asteatosis. 

Class II. Circulatory Disorders. 

1. Hyperemias: 3. OZdemas : 

(a) Arterial: Urticaria, 
Erythema. Prurigo. 

(b) Venous : 4. Hemorrhages : 
Livedo. Purpura, 

2. Anemias: Scorbutus. 

Class III. Inflammations. 

1. Of the corinm a?id snbcutis : Chromophytosis, 

(a) Superficial : Scabies, 

Morbilli, Phtheiriasis, 

Rubeola, Eczema, 

Scarlatina, Erythema multiforme, 

Variola, Herpes, 

Vaccinia, Zoster, 

Varicella, Dysidrosis, 

Lichen planus, Pemphigus, 

Lichen ruber, Dermatitis herpetiformis, 

Favus, Impetigo contagiosa, 

Trichophytosis, Dermatitis exfoliativa, 

Pityriasis rosea, Psoriasis. 

52 



CLASSIFICATION. 



53 



Class III. Inflammations {Continued). 



(b) Deep-seated: 
Dermatitis, 
Erysipelas, 
Erythema nodosum. 

(c) Suppurative: 
Phlegmon, 
Furunculosis, 
Carbuncle, 

(d) Granulomatous: 
Tuberculosis, 
Lupus, 
Syphilis, 



Lepra, 

Mycosis fungoides, 

Lupus erythematosus, 

Rhinoscleroma, 

Actinomycosis. 
Of the glands : 

Hydradenitis, 

Acne, 

Rosacea, 

Folliculitis. 
Of the nails : 

Onychomycosis. 



Class IV. 

1 . Of the epidermis : 

Ichthyosis, 

Keratosis, 

Callositas, 

Clavus, 

Verruca, 

Cornu cutaneum, 

Condylomata acuminata. 

2. Of the connective tissue : 

Elephantiasis. 

Class V. 
i. Of the connective tissue : 

Cicatrix, 

Keloid, 

Fibroma, 

Myxoma, 

Lipoma, 

Neuroma, 

Xanthoma, 

Sarcoma. 

Class VI 
i. Of the cutis and subcutis : 

Atrophia senilis, 

Atrophia maculosa et striata, 

Xeroderma, 

Scleroderma. 
2. Of the pigment : 

Albinismus, 



Hypertrophies. 

3 . Of the glands : 



Molluscum contagiosum. 

4. Of the hairs: 
Hypertrichosis. 

5. Of the nails : 
Onychauxis. 

6. Of the pigment : 
Lentigo, 
Chloasma. 

New Growths. 

2 . Of the muscular tissue : 
Myoma. 

3. Of the vessels : 
Angioma, 
Lymphangioma. 

4. Of the glands : 
Adenoma, 
Carcinoma. 



Atrophies. 



Vitiligo, 

Canities. 
Of the hair: 

Alopecia, 

Alopecia areata. 
Of the nails : 

Atrophia unguis. 



CLASS I. 
FUNCTIONAL DISORDERS. 



Functional disorders, without recognizable anatomical change, and affecting 
sensibility, motion, and secretion, occur in the skin. The changes of sensibility may 
consist of hyperesthesia, anaesthesia, or paraesthesia ; the touch, temperature, or 
pressure sensation may be involved ; or pain may be the only symptom. They are 
not usually independent diseases, but are caused by other local or general maladies. 
Dermatalgia and anaesthesia occur, though very rarely, as idiopathic cutaneous affec- 
tions, and pruritus is the only functional change of sensibility that demands more 
detailed attention. The functional alterations of secretion are more important, 
affecting both the coil and the sebaceous glands. They include the various altera- 
tions of the sweat secretion, known as hyperidrosis, anidrosis, bromidrosis, chromi- 
drosis, etc., and those of the sebaceous secretion — seborrhea, asteatorrhea, and 
comedo. 

PRURITUS. 

Definition. — A functional disease of the skin, characterized by itching without 
any primary cutaneous lesion. 

Symptoms and Course. — Itching occurs as a symptom in various cutaneous mala- 
dies, as well as in a number of other general and local affections ; but it is some- 
times a pure neurosis, occurring idiopathically, and showing no objective signs. 
Certain secondary effects, in the shape of excoriations, blood-crusts, pigmentation 
and induration of the skin, and even eczema, may be present ; but they are caused 
by the patient's finger-nails, and are not an essential part of the disease. They 
appear on the portions of the body most accessible to the sufferer, and they are not 
seen when scratching is prevented, however violent or extensive the pruritus may 
be. It is unfortunate that Hebra, who first described the malady, did not give it a 
name different from that of its only symptom. 

Pruritus universalis is the severest form of the malady, and causes great suffer- 
ing. Not the entire body, however, is affected at one and the same time;, the itch- 
ing attacks various portions of the skin in turn. Pruritus senilis is a not infrequent 
affection in the old. Pruritus hiemalis, first described by Duhring, is apparently 
dependent on the weather, being commonest in northern climates, regularly getting 
better or disappearing as the warm weather comes on, and beginning again in the 
winter. Pruritus aestivus is the opposite to this, and is seen only in summer. Some 

51 



FUNCTIONAL DISORDERS. 55 

cases of the so-called " prairie itch " or " Texas mange " are cases of pruritus; but 
the designation includes cases of parasitic disease also, more especially of scabies. 

Pruritus localis may involve any portion of the body, frequently affecting the 
face and scalp, and sometimes the palms and soles ; but it more often occurs as pru- 
ritus genitalium, in the genito-anal region of both sexes, and is a severe and distress- 
ing affection. Pruritus vulvae may prevent the patient from attending to her duties 
and unfit her for society. Pruritus ani is very common, but is most frequently 
secondary to various rectal diseases. 

The itching may be continuous, and then usually varies in intensity at different 
times and in different portions of the skin. More commonly it is paroxysmal, com- 
ing on more especially under the influence of mental emotions or sudden changes 
of temperature. Frequently it is most severe at night, when the patient is in bed. 
It causes an impulse to scratch that is almost irresistible. The finger-nails, or, if 
these are insufficient, foreign bodies — rough cloths, hair-brushes, sticks, etc. — are em- 
ployed to rub and scratch the skin, which is often torn, lacerated, and covered with 
blood before relief is obtained. The attacks prevent sleep ; the patient emaciates, 
and his general health is impaired. Occurring in the daytime, neither modesty nor 
the presence of others can restrain the impetus scabendi (the " impulse to scratch ") ; 
and the affliction has driven some of these sufferers to suicide. 

Etiology. — Many, perhaps most, cases of so-called pruritus are symptomatic of 
some local or general disease, and not independent affections. Digestive disturb- 
ances, diabetes, jaundice, and Bright's disease are the commonest causes of general 
pruritus ; while the local attacks are due to many various causes, among which may 
be mentioned vaginitis, vulvitis, and utero-ovarian disease in general, balanitis and 
urethritis, rectal fissures and hemorrhoids, ascarides, etc. Pruritus senilis is depen- 
dent on senile atrophy of the skin, with diminution of the sebaceous secretion. In 
most cases of true pruritus, however, the etiology is unknown. 

Pathology. — No pathological changes have been found in the disease, and it is 
classed as a true neurosis. 

Diagnosis. — The other itchy diseases of the skin — prurigo, scabies, phtheiriasis, 
urticaria, etc. — all have objective symptoms which enable them to be readily distin- 
guished from pruritus, which has none. Even prurigo, the disease with which it is 
most liable to be confounded, has its primary papules and infiltrated skin, and be- 
gins at a very early age and continues through life. 

Prognosis is doubtful and often bad. Very frequently no underlying cause can 
be found, and the senile changes of the skin are permanent. 

Treatment. — The great number of remedies recommended in this disease is a 
sure index of the inadequacy of our attempts to cope with it. Especial attention 
must be paid to the gastro-intestinal tract. The bowels must be kept regular with 
salines, and coffee, liquor, and all indigestible food must be forbidden. General 
hygiene, and especially proper exercise, must be insisted on. Tonics — iron, qui- 





No. 10. 7tfr Spirit. 




No. U. 1 


ft 


01. cadini 


ft 


Acidi carbolici 




Spts. vini . . . . aa. p. e. 




Spts. vini 
Glycerini 




No. J2. Menthol Ointment. 






ft 


Menthol i part 




No. 13. V 




Ol. olivae .... 3 parts 


ft 


Veratrise 




Adip. lanas . . . . 24 " 




Ungt. simpl. 



56 ILLUSTRATED SKIN DISEASES. 

nine, cod-liver oil, and nux vomica — are occasionally useful. The bromides in 
large doses sometimes relieve the itching; and salicylate of sodium, in daily doses 
of from 30 to 60 grains, has occasionally done good. Saalfeld recommends hypo- 
dermic injections of \ grain of pilocarpine. 



2 parts 
10 " 
90 



1 part 
. 150 parts 

Medicated baths of sulphur, tar, or bran occasionally do good. A good way is to 
sponge the affected areas with tar spirit (No. 10, p. 56), and then immerse the body for 
one half to one hour in a warm bath. The tar must not, however, be used over the 
entire body for fear of poisoning. The local anesthetics are perhaps our most 
valuable remedies. Carbolic acid may be employed as a lotion (No. 11, p. 56), or 
menthol in solution with alcohol or as a salve (No. 12, p. 56). Liquor plumbi subace- 
tatis (3i to water, |i) and cocaine in 5- to 20-per-cent. vaseline ointment may also be 
employed. Bulkley recommends the inunction of chloral-camphor, a thick liquid 
obtained by triturating together equal parts of the two drugs ; and Joseph cured 
some cases by painting the surface daily with the tincture of benzoin. Others have 
employed veratria with success in pruritus vulvae (No. 13, p. 56), using both in oint- 
ment and internally in pills of -j4o OI a grain. In obstinate cases the Pacquelin may 
be used, cauterizing the parts superficially ; and even excision of the affected parts 
has been recommended. Unfortunately many cases resist all these measures. 



There are no functional disorders of the skin in the motor sphere of any impor- 
tance. The arrectores pilorum are the only muscular structures. Their temporary 
contraction under the influence of cold or of the emotions causes the erection of the 
hairs and the elevation of the epidermis around them, being the condition known 
as cutis anserina or goose-flesh. Functional disorders of the glandular structures 
are, however, of more importance. The sweat may be increased in amount (hyperi- 
drosis) or diminished (anidrosis) or changed in quality (bromidrosis, chromidrosis, 
uridrosis, hematidrosis). 

HYPERIDROSIS. 

Definition. — A functional disease of the coil glands, consisting of excessive secre- 
tion of the sweat. 



FUNCTIONAL DISORDERS. 57 

Symptoms and Course, — Sweating occurs physiologically when the body is ex- 
posed to heat or when muscular exertion is undertaken. Pathologically it is a 
symptom in many abnormal conditions, as of collapse, shock, and fainting, and in 
asthma, rickets, exophthalmic goitre, rheumatism, malaria, etc., and in the deferves- 
cence of fevers. It is then a hyperidrosis universalis, affecting the whole body, and 
frequently coming on in paroxysms at night. The excessive secretion macerates 
the epidermis and frequently causes inflammation of the skin in localities where the 
approximation of opposing folds favors retention of the fluid and debris (eczema 
intertrigo). Miliaria and sudamina are common complications, as are also the my- 
cotic diseases (chromophytosis, trichophytosis, etc.). Being a symptomatic affection 
in most cases, its special consideration need not be entered upon here. 

Hyperidrosis localis is more essentially a cutaneous affection. It is very fre- 
quent, especially on the head, hands, and feet. It may be unilateral or bilateral, or 
it may affect certain special areas of the skin. Hyperidrosis pedum is perhaps its 
commonest and most troublesome form. The feet are continually wet and cold ; the 
socks are soaked ; the skin is macerated, and may even become excoriated or ulcer- 
ated. Confined in the shoes, the fatty material of the sweat and epidermic cells 
decomposes, and a peculiar nauseating odor is caused that may be perceptible to 
others, and, in the worst cases, may render the patient unable to go into society 
(bromidrosis). Walking is sometimes so interfered with that the sufferer is practi- 
cally bedridden. 

Hyperidrosis manuum is also quite common, and is almost as great an affliction. 
The hands are perpetually moist and greasy ; they stain every article that they 
touch, and gloves can hardly be worn at all. Sometimes the secretion is so abun- 
dant that the sweat drips from the finger-tips when the hands are at rest. The 
affection occurs most commonly in nervous and anemic women. Hyperidrosis 
axillae and hyperidrosis genitalium frequently predispose the skin of the affected 
parts to intertrigo and eczema marginatum. Like all the other forms of the disease, 
they are commoner and more annoying during hot weather. 

Etiology. — The cause of the excessive sweating, when not one of the above- 
mentioned diseases, is often undiscoverable. Some derangement of the sympathetic 
nervous system is probably at the bottom of it. Uncleanliness certainly plays no 
part. Mental excitement frequently seems to start the flow. I have noticed that 
the workmen in the aniline factories, who cleanse their hands of the dyes with 
chloride of lime, suffer from severe hyperidrosis of the hands ; the affection stops, 
however, as soon as they cease to use the lime. 

Pathology is practically wanting. The secreted sweat is apparently normal, and 
Robinson has examined many sections of hyperidrotic skin without finding anything 
abnormal about the sweat-glands or their epithelium. 

Diagnosis never presents any difficulties, though the underlying cause is some- 
times impossible to find. 



58 



ILLUSTRATED SKIN DISEASES. 



Prognosis should be guarded ; many cases are very intractable. Death has oc- 
curred, apparently from the exhaustion caused by severe hyperidrosis alone, in the 
case of an old man reported by Myrtle. 

Treatment. — There is, of course, no truth in the popular idea that checking of 
the sweat secretion, like driving away an eruption, is liable to occasion internal 
disease. The cause must be treated when it can be found. The use of water, 
macerating the already swollen epidermis, must be limited to the smallest necessary 
amount. The clothing should be woolen, and very frequently changed ; twice a 
day is none too much for the socks in hyperidrosis pedum. Sleeping between 
woolen blankets rather than between sheets, and with the least amount of covering 
that can be borne, will tend to lessen the distressing attacks of sweating that occur 
during the night in various diseases. 

Of internal remedies there are recommended the usual large number when deal- 
ing with a more or less intractable disease. The only ones that I have found of 
value, in addition to the general and the bitter tonics, are : atropin, given hypoder- 
mically in doses of y-J-^ to ^5- of a grain, and increased up to the point of toleration ; 
ergot in 3ss doses twice daily; and aromatic sulphuric acid, 10 to 20 drops three 
times a day. Crocker recommends sulphur, 3i in milk twice a day, very highly ; I 
have had no experience with it. 



No. 14. Salicylic Dusting Powder. 



R Ac salicylic . 
Talci . 
Amyli . 



3 parts 

7 " 
90 " 



No. 15. Alum Dusting Powder. 



f£ Aluminis 
Ac. salicylici 
Amyli . 



aa. 



No. 16. Quinine Dusting Powder. 



% Quin. sulph. 
Amyli 



1 part 
5 parts 



External treatment should consist of washing the affected area with vinegar, 
cologne water, or alcoholic solutions of naphthol 10 per cent., tannin 5 per cent. ; 
or salicylic acid 1 per cent., followed, after thoroughly drying the parts, by a dust- 
ing powder (Xo. 14, p. 58). The tincture of belladonna, diluted with equal parts of 
water, is a good application in some cases; there need be no fear of absorption and 
poisoning if fissures or excoriations are not present. Where the abnormal sweating is 
limited to a small area, a 5-per-cent. solution of chromic acid painted once or twice 
over the part has done me good service ; but it should only be used about once in 
two weeks. 

In hyperidrosis pedum the feet should be washed daily with a decoction of white- 
oak bark, then carefully dried, and one of the alcoholic solutions recommended 
above applied. The parts should then be well dusted with an astringent powder 



FUNCTIONAL DISORDERS. 59 

(No. 15, p. 58), pledgets of cotton being placed between the toes. Hebra's celebrated 
treatment consists in laying diachylon ointment spread on strips of linen on the feet 
and between the toes. The dressing must be changed daily for two weeks without 
washing, the parts being simply wiped dry with a cloth. Desquamation of the 
epidermis occurs, and with it a diminution of the amount of the sweat. Morrow 
recommends foot-baths of the extract of Pinns Canadensis, followed by one of the 
various dusting powders. 

Hyperidrosis manuum is best treated by an alcoholic alum or tannin solution. 
G. H. Fox recommends an alcoholic solution of quinine, I to 100, very highly. 
Any of these may be followed by a quinine dusting powder (No. 16, p. 58). 

Hyperidrosis genitalium may be treated by washing the parts with a decoction 
of white-oak bark, followed by powder. A suspensory bandage must be worn by 
the male ; and in either sex it is advisable to use bandages and layers of absorbent 
cotton to prevent the affected areas coming in contact. In hyperidrosis axillae the 
dusting powder may be worn in small linen bags slung round the shoulders or at- 
tached to the clothing. 

ANIDROSIS is not a definite disease of the skin, but is a diminution in the amount 
of the sensible perspiration below the normal. It occurs in various diseases ; in 
fevers, diabetes, and various maladies of the brain and spinal cord, as well as in 
ichthyosis, scleroderma, prurigo, and some forms of eczema and psoriasis. Treat- 
ment must be directed to the malady of which it is a symptom. Steam and Turk- 
ish baths, general tonics, exercise, etc., do good; and pilocarpine hypodermically in 
small doses may be tried. 

BROMIDROSIS. — The exhibition by the sweat of a peculiar and usually disagreea- 
ble odor is not a distinct malady, but is either symptomatic of other affections or is 
due to the decomposition of the sweat under the influence of bacterial life. Sympto- 
matic general bromidrosis occurs in some of the exanthemata and fevers where the 
sweat has a distinctive odor (variola, typhus). A few drugs, such as sulphur, iodine, 
and musk, also cause it. But the commonest variety is the local bromidrosis oc- 
curring in connection with hyperidrosis of the axillae, the genitals, and more espe- 
cially of the feet. Hebra has proved that even in the worst of these cases the sweat 
is odorless when excreted ; and it has been shown that the fetor that supervenes is 
due to the growth of the Bacterium fetidum in the exuded sweat and sebum. 

The odor of bromidrosis is a heavy and peculiar one, and has been compared by 
Crocker to that of moldy cheese. The clothing covering the affected part, more es- 
pecially the socks and shoes, is its source, rather than the skin itself. This latter 
is tender, red, and excoriated; or the epithelium may be swollen by the excessive 
secretion, and it becomes sodden and white. Its cause is most often the organism 
mentioned above. But hyperidrosis is usually associated with it, and our custom 
of enveloping the feet in an impervious leather covering favors its development. 

The treatment is essentially that of hyperidrosis. Frequent bathing and change 



60 ILLUSTRATED SKIN DISEASES. 

of clothing are essential. Thin's plan is effective,, and consists in first soaking the 
clean socks in a solution of boric acid and letting them dry. The feet are then well 
powdered with the acid, which is also dusted freely in the socks and shoes. A 
solution of the permanganate of potassium, I to 3 grains to the ounce, and applied 
to the feet several times a day, is also useful. Chromic acid in 5-per-cent. solution 
may be applied cautiously once in two or three weeks. In the German army it has 
been found useful, especially when on the march, to anoint the feet with suet con- 
taining 2 per cent, of salicylic acid, and then to wrap up the feet in bandages soaked 
in the same instead of using stockings. Crocker has obtained good results from 
the internal use of sulphur, as in hyperidrosis. 

CHROMIDROSIS or colored sweating is an extremely rare malady. The reported 
cases have occurred mostly in hysterical women, and some of them have been found 
to be the result of imposture. The very existence of the affection has been doubted, 
but a sufficient number of cases have been seen by competent observers to prove 
that it occurs. Blue, yellow, brown, and red sweat have been seen, but the source 
and nature of the coloring- matters are not definitely known. Pyocyanine, the color- 
ing-matter of blue pus, and indigo, have been thought to be the cause of the cases 
of blue sweating observed by Hofmann, Le Roy de Mericourt, and T. C. Fox. The 
yellow and the black colors respectively of the secretion in the cases of Mibelli and 
Kollmann were apparently due to the ingestion of chrysarobin and of phosphate of 
iron. On the other hand, Babesieu and others have reported cases that were un- 
doubtedly bacterial in origin. In most instances the sweating has been confined to 
a very limited area, the lower eyelids being most frequently affected. The treat- 
ment attempted has been entirely useless. 

Uridrosis, or the excretion of urea with the sweat, is simply an exaggeration of a 
normal condition, that compound being always present in the secretion. It occurs 
in certain general conditions, as in cholera, but is more commonly seen in uremia, 
where the amount of urea excreted by the coil glands may not only give the sweat 
a urinous odor, but may be deposited in the form of minute white crystals on the 
surface of the skin. 

HEMATIDROSIS or bloody sweat is sweat containing a number of red blood-cells 
that have escaped from the vessels by diapedesis. This extremely rare affection 
occurs in persons suffering from hemophilia, and is then associated with hemorrhages 
and blood-extravasations in the various organs and tissues. The subjects affected 
have always been hysterical women, and the process has been regarded as a vicarious 
menstruation. The case of Louise Lateau with " bleeding stigmata " is well known. 

SUDAMINA. 
Synonym. — Miliaria crystallina. 

Definition. — Retention cysts of the coil glands, appearing as discrete, pinhead- 
sized, translucent vesicles containing sweat. 



FUNCTIONAL DISORDER? 



1)1 



Symptoms and Course. — The vesicles look like drops of dew upon the surface of 
the skin, and are usually present in large numbers. They may appear on any part 
of the body, but the neck, chest, and abdomen are most frequently affected. They 
never become pustular or coalesce or show any signs of inflammatory reaction. 
After persisting for a day or two they dry up ; and their disappearance is followed 
by a slight furfuraceous desquamation. 

Etiology and Pathology. — Sudamina is essentially dependent on general hyperi- 
drosis, and is most commonly seen in diseases characterized by abundant sweat- 
ing (phthisis, rheumatic fever, typhoid, etc.). Violent exercise, excessive warmth of 
the clothing, and exposure to moist heat will also cause its appearance. Robinson, 
who has carefully studied their anatomy, finds that the fluid is an accumulation of 
pure sweat under the corneous layer, the duct of a coil gland opening into each 
little cyst. 

Treatment. — The treatment of sudamina is usually unnecessary, since they are 
most often phenomena of little importance occurring in the course of other diseases. 
The general treatment recommended for hyperidrosis may be employed. If they 
cause any annoyance a mildly astringent lotion (No. lj, p. 61) may be sponged over 
the affected area. The zinc-and-starch powder (No. 18, p. 61) is also useful. 



No. J7. Lead Lotion. 

fy Liq. plumbi subacet. dil. . 3 parts 

Glycerini . . . 8 " 

Aq. cologniensis . 16 " 

Aq. destil 60 " 



No. J8. Zmc Dusting Powder. 

1 part 

aa. 4 parts 



fy Pulv. zinci ox. . 
Talc, venet. 
Amyli . . 



SEBORRHEA. 

Synonym. — Steatorrhea. 

Definition. — Seborrhea is a functional disease of the sebaceous glands, character- 
ized by an excessive and abnormal secretion of sebum, which appears as an oily 
coating or as crusts upon the skin. 

Symptoms and Course. — Seborrhea occurs anywhere where there are sebaceous 
glands, and is commonest upon the scalp, the face, the genitals, and the anterior 
and posterior surfaces of the chest. The affection may be a slight one, limited in 
area, and readily removed ; or it may be extensive and severe, and very rebellious 
to treatment. We distinguish two separate clinical forms, in accordance with 
whether the sebaceous material that accumulates upon the skin is fluid and oily, or 
solid, forming crusts and scales. 

Seborrhea oleosa is the more frequent form of the affection, especially in the 
negro race, where it is so frequent as to be almost the normal condition. The skin 
is greasy to the touch, and glistening, and the fatty material may even be abundant 
enough to accumulate as minute drops of oil. It occurs on the nose and face, and 
bald scalps are rendered more shining by its presence. The dust and coal-soot of 



62 



ILLUSTRATED SKIN DISEASES. 



the atmosphere settle on the oily coating and stick there, giving to the skin a 
dirty gray or blackish appearance. The ducts of the sebaceous glands are usually 
markedly dilated, and may be seen large and patulous, or plugged with comedones. 
Seborrhea sicca is also a common condition, affecting both the hairy and the 
non-hairy regions of the body. It is of especial frequency upon the scalp, and is 
the common cause of premature baldness. It appears as thin, white, and greasy 
scales, which become yellowish or brownish as they desiccate and become dirty. 
The skin beneath is grayish white and anemic, and when excessive accumulation of 
the scales causes irritation, a mild eczematous inflammation is set up. 

Seborrhea may in rare cases be universal. This is physiological in the new-born 
infant, where the half-dried sebaceous secretion forms the vernix caseosa. The super- 
abundant secretion usually continues in the scalp during the first year of life, and 
where there is not sufficient cleanliness accumulates in thick dark-yellow or brown- 
ish masses, the so-called " cradle crust." But in most cases seborrhea is partial and 
affects only a limited area of the skin. 

Seborrhea capitis is the commonest form of the malady, and, as the chief cause 
of baldness, one of the most important. The excessive glandular secretion accumu- 
lates as more or less fatty, dirty yellowish-white scales, occupying circumscribed 

areas or diffused over the entire 
scalp. The hairs are fatty and 
sticky, and become matted to- 
gether, and want of cleanliness 
may lead to a tangling up of the 
hair with sebum and dirt. Later 
on there occurs excessive cornifi- 
cation and desquamation of the 
epithelial cells ; and the mingled 
sebum and scales are cast off as 
dandruff, the white scales of which 
powder the patient's clothes. 
Being unaccompanied by any 
subjective sensation further than 
a moderate itching, this condition 
is usually allowed to persist for 
years without treatment, and it is 
only when the final stage sets in 
that medical aid is sought. The 
hairs then lose their luster and get loose ; the follicles begin to atrophy and the hair 
to fall out. The baldness begins upon the vertex, or above the forehead, and may 
go so far that only a fringe of hair is left around the nape of the neck and the ears. 
The denuded scalp is shiny, and attached firmly to the skull beneath. More rarely 




Fig. 29. — Seborrhea capitis. 

From photograph in the author's collection. 



FUNCTIONAL DISORDERS. 63 

than upon the head a similar process takes place in the mustache, beard, and eye- 
brows. In some of these cases there is more or less hyperemia; epithelial prolifera- 
tion is a more prominent factor; the itching is more intense ; and they stand on the 
boundary line between pityriasis and the malady under consideration. 

Seborrhea facei and seborrhea nasi are common localizations of the disease, and 
appear both in the oily and the dry form. In the former the alae nasi and the 
cheeks are the parts most commonly affected. The skin is covered with a layer of 
oily matter, mingled with more or less dirt from the atmosphere. The mouths of 
the glands are large and prominent, and comedones, acne papules, and rosaceous 
patches are often present. In the dry form the sides and tip of the nose and the 
forehead are covered with small, dark-yellow, fatty, adherent scales, and the skin 
beneath is frequently irritated. 

Seborrhea genitalium is common in both the male and the female, more espe- 
cially when cleanliness is not observed. The sebaceous glands of the labia and fossa 
of the glans are large and numerous ; sebum accumulates and decomposes, giving 
rise to a foul and characteristic odor, and inflammation and excoriations may be the 
secondary results. 

Etiology. — General impairment of health seems to be the main predisposing 
factor to the disease ; it occurs most commonly in anemic and chlorotic individuals 
suffering from irregularities of the bowels or of the menstrual function. Neverthe- 
less it is often seen in robust individuals, in whom we are at a loss to account for 
its advent. 

Pathology. — The disease process in pure seborrhea is an entirely functional one, 
and the sebaceous glands themselves are not in any way changed. The difference 
between the oily and the dry form depends on personal peculiarities, and Duhring 
claims that brunettes most commonly have the former, while individuals of a light 
complexion suffer oftenest from the latter variety. Some authorities believe, with 
Jessner, that a low, chronic inflammatory process is present in most cases, an opin- 
ion which is supported by the atrophy of the glandular structures that finally occurs. 
We may follow Unna in classifying the more inflammatory forms of the affection 
by themselves, and considering them under the heading of seborrheal eczema, 
leaving the ordinary forms to represent the functional disease. 

Diagnosis. — Seborrhea, more especially of the scalp, must be differentiated 
from eczema, psoriasis, and lupus erythematosus. As regards eczema, the sebor- 
rheal crusts are fatty, and are not composed of inflammatory exudation ; and the 
skin beneath them is dry and white, or at the most slightly reddened, not moist, 
thickened, and inflamed. In psoriasis the scales are large and silvery white ; in 
seborrhea they are smaller, grayish, and fatty. The skin of a psoriasis patch is 
reddened, while that of a seborrheal area is pale and anemic ; and we will always in 
the former disease find other patches, more especially on the outer surfaces of the 
joints. The distinction from lupus erythematosus is more difficult, and may in some 



64 



ILLUSTRATED SKIN" DISEASES. 



cases be impossible. This is the less to be wondered at from the fact that, as Hebra 
long ago pointed out, erythematous lupus begins as a congestive form of seborrhea, 
and persists as such for a long time before taking on a characteristic form. But 
lupus erythematosus is distinctly inflammatory, the skin is thickened and infiltrated, 
and superficial scars result in the center of the patch as the disease progresses ; 
moreover, it is rare on the scalp. Seborrhea, on the other hand, shows no inflam- 
matory reaction and no scar tissue ; its scales are soft and fatty, and its favorite 
location is upon the head. 

Prognosis. — The general prognosis of seborrhea is good, though some cases are 
very obstinate, especially where the genitals are affected. In seborrhea of the 
scalp also, our opinion as to the possibility of a regrowth of hair must be a guarded 
one. We have no means of telling what proportion of the hair-follicles are still 
capable of growth. The patient should also be informed that treatment will inev- 
itably cause an increased falling out of the hairs at first, but that none will be lost 
that are not loosened and ready to come out, while feeble ones will be strength- 
ened and stimulated. 



No. 19. Startups Mixture. 

ft Magnes. sulphat. . . 16 parts 

Ferri sulphat. ... i part 

Acid, sulph. dilut. . . 3 parts 

Infus. quassias . . ad. 30 " 

S. A teaspoonful in water, after eating. 



No. 21. Tannin-Resorcin Spirit. 

ft Ac. tannic, or resorc. albissim. 1 part 
01. ricin. . . . 1 " 

Spirit, coloniensis . . 50 parts 



No. 23. Bronsoif s Mercurial Ointment. 



No. 20. Resorcin Ointment. 



ft Hg. ammoniati 
Hg. chlor. mit. 
Petrolati 



1 part 

2 parts 



ft Resorc. albissim. 
Sulph. depur. 
Adip. lana? 
Ungt. simpl 



aa. 1 part 



aa. 



parts 



No. 22. Tor Ointment. 



ft 01. cadini 
Ungt. simpl. 



1 part 
8 parts 



No. 24. Sulphur Paste. 



ft Sulphur, depur. 
Pulv. zinci ox. 
Amyli 
Petrolati . 



1 part 

aa. 2 parts 
5 " 



No. 25. Sulphur Ointment. 



ft Sulphur, lot. 
Ungt. aquae ros. 



1 to 2 parts 

8 " 



Treatment. — The treatment of seborrhea is, above all things, a matter requiring 
much time and great patience. The general treatment must be directed to regu- 
lation of hygiene and correction of any ascertainable fault in gastro-intestinal and 
uterine functions. Fresh air, abundant exercise, daily salt-water baths, and proper 




TYP03RAVURE. 



COPYRIGnT, 19C2, BY E. B. TREAT & CO. . N. Y. 



COMEDO AND ACNE. 



PLATE I_V. 






Th 

■ 

the parts n 

3 

the rest 
The vai 
the affe< 
In E 
move the c 

oini 

until thi 
ur most 
nbination 

or ■ 

equired 

In seboi 



eat c 












Dcfi 







COMEDO AND AC 



FUNCTIONAL DISORDERS. 65 

food are of importance ; cod-liver oil is frequently indicated in anemic cases, "Where 
Startin's acid iron mixture (No. 19, p. 64) also does good service. 

The local treatment consists in removing the crusts and lessening the excessive 
secretory action of the sebaceous glands. The former is effected by softening them 
by the continuous application of cloths soaked thoroughly with olive-oil, sweet- 
almond oil, cod-liver oil, or glycerin. If the scalp is affected, a piece of oil silk or 
a bathing-cap should be worn during the night to protect the bedclothes and keep 
the parts moist. If this is not sufficient, green soap should be employed, best in 
the form of the spiritus saponis kalinus recommended by Hebra (No. 5, p. 43). 
This used as a shampoo with hot water once a day, with the oils as above described 
during the rest of the time, will cause most of the crusts to disappear, and so soften 
the rest that there is no difficulty in removing them with a soft cloth or a comb. 
The various sulphur, resorcin, and tannin lotions and salves can then be applied to 
the affected skin (Nos. 21, 24, 25, p. 64). 

In seborrhea capitis the above preliminary treatment should be employed to re- 
move the crusts, and, since they accumulate quite rapidly, it must be repeated once 
or twice a week during the entire course of the treatment. It is never necessary to 
cut the hair ; by carefully parting it and using a hard-bristle brush dipped in the 
ointment or lotion, and brushing it into the scalp, successive areas of skin may be 
treated until the whole has been covered. Sulphur in 5- to 10-per-cent. ointment 
is our most valuable remedy, and resorcin is almost as effective. I have found the 
combination (No. 20, p. 64) very useful. As the secretion diminishes, tannic acid 
or resorcin in alcoholic solution is preferable (No. 21, p. 64). In obstinate cases tar 
is required (No. 22, p. 64), and the ointment recommended by Bronson is very ser- 
viceable (No. 23, p. 64). 

For seborrhea of the face the spiritus saponis kalinus is too irrtant, and the 
crusts must be removed by the use of one of the medicated soaps, those of ichthyol, 
resorcin, and sulphur being most employed. A 5-per-cent. sulphur paste (No. 24, 
p. 64) or the resorcin ointment (No. 20, p. 64) may be applied. 

In seborrhea of the body, sulphur, 10 to 30 grains to the ounce of adeps lanas, 
is most useful. Seborrhea of the genitals is treated by keeping the parts clean with 
ordinary soap and warm water, followed by the application of a slightly astringent 
dusting powder (No. 15, p. 58; No. 18, p. 61). 

The treatment of seborrhea oleosa differs in no way from that of the dry form 
of the disease, save that the preliminary treatment for the removal of the crusts is 
not required. 

COMEDO. 

Synonyms. — Blackhead, Mitesser (Ger.), acne ponctuee (Fr.). 

Definition. — A disease of the sebaceous glands, characterized by pin-point- or 
pinhead-sized papules, with minute bluish or black centers. 



66 



ILLUSTRATED SKIN DISEASES. 



Symptoms and Course. — Blackheads are present to some extent in all skins, and 
are frequently numerous enough to form an annoying deformity. This is especially 
the case at the time of puberty, when the sebaceous follicles participate in the 

general glandular development of 
the skin that takes place at that 
time. The comedones appear as 
minute blackish or bluish points, 
each one of which marks the situ- 
ation of the mouth of a gland. 
They are almost always accom- 
panied by more or less seborrhea, 
and the irritation of the retained 
secretion frequently causes an in- 
flammatory acne. Their seat is 
most often on the face, the fore- 
head, nose, and chin being more 
especially affected ; but they oc- 
cur also in the lobe of the ear and 
behind it, and on the nape of the 
neck. The back is sometimes 
extensively affected, and they 
have even been found on the 
penis. 

Etiology. — We do not know- 
why comedones develop ; but 
dirt, formerly supposed to be the 
cause of their appearance, has 
nothing to do with it. Uncleanly 
people and those whose avoca- 
tions expose them to dirt and 
dust are perhaps less liable to them than those of unexceptionable personal habits 
and refined occupations. Thick, muddy skins with well-developed and patulous 
sebaceous glands, and with a tendency to seborrhea, show them most frequently. 
Anemia and chlorosis, and the general causes of seborrhea, are undoubtedly of in- 
fluence in their formation. 

Pathology. — The black plug which closes the dilated orifice of the sebaceous 
gland consists of masses of epithelial cells and detritus, inspissated sebum, choles- 
terin crystals, and minute lanugo hairs. The little parasite known as the Acari/s or 
Demodex folliailoriini is frequently found in the mass; but it is not the cause of 
the affection, being non-pathogenic in man, though in the dog it causes what is 
termed follicular mange. The color of the comedo is not due to the accumulation 




Fig. 30. — Comedo. 
Case of Dr. J. F. Aitken. 



FUNCTIONAL DISORDERS. 



67 



of dust from the atmosphere, as was formerly supposed ; Unna has clearly demon- 
strated that it is caused by a peculiar black, blue, or brown pigment. 

Diagnosis needs no consideration. Milium is closely allied to comedo, but has 
no central duct closed with the character- 
istic black plug. 

Prognosis is good as to the immediate 
removal of thedisfigurement ; but thecome- 
dones frequently return with an annoying 
obstinacy, and some cases are not perma- 
nently curable. 

Treatment consists in removing the 
cause, and more especially the seborrhea 
that is so frequently present. Fresh air, 
sea-bathing, tonics, and other hygienic 
measures are useful. Local treatment must 
begin with the use of plenty of hot water 
and soap, and an alkaline lotion, such as a 
5-per-cent. solution of bicarbonate of soda, 
to soften the plugs. The comedones can 
then be removed with the expresser. The 
old-fashioned watch-key and instruments 
fashioned like it are not appropriate ; they 
injure and bruise the skin, become clogged 
very rapidly, and cannot be kept clean. 
Blunt-edged, curette-shaped instruments 
(Fig. 1 6, p. 50), by means of which lateral 

pressure can be exerted on the ducts of the glands and the plugs expressed, are much 
better. The rounded handle of the ordinary metallic pocket-case instruments makes 
a very useful comedo extractor when none other is handy. The after treatment 
consists of frequent hot ablutions and the use of an alkaline soap to prevent, if pos- 
sible, the inspissation of the sebum in the ducts. A sulphur ointment (No. 25, p. 64) 
is also useful. 




Fig. 31. — Comedo gigantica. 

From photograph in the author's collection. 



MILIUM. 



Synonyms. — Grutian, Hautgriesz (Ger.), acne miliaire (Fr.). 

Definition. — Milium consists in the formation of small, hard, round, whitish, 
non-inflammatory subepidermal tumors of the skin. 

Symptoms and Course. — The small, pearl-white, millet-seed-sized elevations that 
are characteristic of the disease may occur anywhere where there are sebaceous 
glands, but are found most frequently on the face, in the region of the eyelids, 
temples, and cheeks, and on the penis and scrotum. There may be only one or 



68 ILLUSTRATED SKIN DISEASES. 

two, but frequently they are very numerous. They occur at all ages, but are most 
common during the first two years of life. 

Etiology. — The cause of milium is similar to that of comedo ; they are retention 
cysts caused by the obliteration of the ducts of the sebaceous glands. We do not 
know why or under what circumstances this obliteration occurs. 

Pathology. — The cysts are situated in the corium, and are covered with a layer 
of epidermis that seems to be thinned out by pressure. Their contents are seba- 
ceous matter, with epithelium-cells and cholesterin crystals. In rare instances they 
become infiltrated with lime salts, forming cutaneous calculi. Once formed, they 
remain stationary for years, and are obnoxious solely on account of the deformity 
that they occasion. 

Diagnosis. — Milium is distinguished from comedo in that it has no dilated gland 
duct, and no blackhead plugging it. The seborrhea and acne that so frequently 
accompany comedo are also absent. It can hardly be confounded with xanthoma, 
which occurs later in life and never in children, is yellow in color, soft in consis- 
tence, and cannot be squeezed out after incision. 

Prognosis is good ; the malady is a purely local one, and can be readily re- 
moved. 

Treatment. — This consists in incising the epidermis over each tumor, and squeez- 
ing or shelling it out. To obliterate the acinus and prevent reaccumulation of the 
sebum, Piffard's recommendation to touch the inside of each follicle with tincture 
of iodine, or that of Hardaway to use the electrolytic needle in the way recom- 
mended for the electrolysis of hairs, may be followed. 

SEBACEOUS CYST. 

Synonyms. — Steatoma, wen, Balggeschiviilst (Ger.), loupe (Fr.). 

Definition. — Encapsulated cystic tumors containing sebaceous matter, and situ- 
ated in the corium or subcutaneous connective tissue. 

Symptoms and Course. — Wens appear as rounded or flattened, freely movable 
tumors of the skin, covered with the epidermis. Their size varies greatly ; the small- 
est are not larger than millet seeds, while the larger ones may be as big as an egg 
or even an orange. Most often they are soft, their contents being semifluid ; but 
they may be harder, more especially if calcareous infiltration has occurred. They 
may appear anywhere on the body where there are sebaceous follicles; their favor- 
ite location is the scalp, but the face, the scrotum, and the back are not infrequently 
affected. Growing very slowly, they usually remain quiescent for years after attain- 
ing a certain size ; and, since they give rise to no subjective symptoms at all, they 
are obnoxious only on account of the deformity that they cause. Wens are often 
single, and it is rare to find more than a few on one individual. They sometimes 
terminate spontaneously by suppuration and ulceration. 



FUNCTIONAL DISORDERS. 



69 



Etiology. — Wens may be considered as developments of the affections previously 
considered, milium and comedo. They arise from the obliteration of the duct of a 
sebaceous gland, with accumulation of the secre- 
tion that continues to be formed within it. 

Pathology. — The tumors have a distinct and 
firm cyst wall, and soft, cheesy, and semifluid or 
harder yellowish-white contents. These latter 
are often fetid, and consist of sebum, epithelial 
cells, cholesterin crystals, and an occasional lanugo 
hair. Cheesy and calcareous degeneration fre- 
quently occurs, and the thickening of the cyst 
wall is evidently due to the pressure of the seba- 
ceous matter in its cavity. To this cause also is 
to be attributed the atrophy of the hair-follicles 
and the falling of the hair on the surface of the 
tumors. 

Diagnosis. — Fatty tumors are the only growths 
likely to be mistaken for wens ; but they are situ- 
ated most often on the back, buttocks, and ex- 
tremities, and are distinctly lobulated, while wens 
are generally located on the scalp and neck, and 
are of even consistency throughout. 

Prognosis is good; there will be no return of the tumor if the cyst wall is re- 
moved. Carcinoma has occurred after operation, however, as in the case that 
Bryant reported. 

Treatment. — Excision is the only remedy. The entire cyst should be dissected 
out whole if possible ; if the tumor be ruptured or cut into, the wall should be seized 
and carefully removed afterward. If operation is to be avoided, the contents of the 
sac may be expressed through the duct of the gland if it is still patent, or through 
a small artificial opening, and the cavity afterward injected with tincture of iodine. 




Fig. 32. — Sebaceous cyst. 

From photograph in the author's collection. 



ASTEATOSIS. 

Definition. — An abnormal diminution in the amount of the sebaceous secretion. 

Symptoms and Course. — The skin, being deficient in the fatty matter that nor- 
mally renders it soft and pliable, is dry, harsh, inelastic, and readily fissured. The 
hairs are dry and lusterless, and finally fall out. The affection may be general or 
partial, as well as idiopathic or symptomatic. Idiopathic asteatosis is very rare, but 
symptomatic partial or general asteatosis is commoner, occurring in many diseases. 

Etiology. — Symptomatic asteatosis occurs in various constitutional diseases, as 
in ichthyosis, hereditary syphilis, cancer, diabetes, and leprosy ; it is a very common 



70 ILLUSTRATED SKIX DISEASES. 

result of senile marasmus. Local forms of the affection occur from the action of 
various mechanical, chemical, and physical irritants. It may originate in exposure 
to cold, or, as is frequently the case with washerwomen, in the excessive use of 
water and alkaline soaps. Alcohol and alkaline solutions also cause it. 

Prognosis. — This depends upon the cause. If this is removable the disease can 
be cured ; but if the asteatosis is due to some serious malady, as cancer, or to a 
congenital deficient development of the sebaceous glands, as in ichthyosis, or to 
their atrophy, as in old age, the affection is incurable. 

Treatment. — The cause of the asteatorrhea must be removed if possible. The 
excessive use of water must be avoided, and a superfatted soap substituted for the 
alkaline and irritant varieties. We have no means at our disposal to increase the 
sebaceous secretion, and we can therefore only attempt to supply its deficiency by 
external applications. Any of the various animal fats, almond-oil, cod-liver oil, or 
olive-oil may be used for the daily inunction. Ungt. aq. rosae, cold-cream, is use- 
ful. Adeps lanae, with vaseline (No. 26, p. 70), or the salol-menthol oil (No. 27, 
p. 70) may be employed with advantage. 

No. 26. Simple Ointment. No. 27. Salol-Menthol Oil. 

3: Adip. lanae . 
Petrolati 
01. rosae. 1 part 01. oliv. . . . aa. part. aeq. 

Glycerin is an excellent application, but it must be used diluted with water. 
Pure glycerin is not only an irritant, but it still further dries the skin by abstracting 
water from it. In bad cases washing must be stopped entirely for a time, and Las- 
sar's paste (No. 2, p. 43) should be used freely on the affected parts. 



50 parts 


$ Salol 


50 " 


Menthol 


1 part 


01. oliv. 



CLASS H. 

NON-INFLAMMATORY CIRCULATORY 
DISTURBANCES. 



In this class we place the various affections that are characterized by changes in 
the normal distribution of blood in the skin, but unaccompanied by any inflamma- 
tory phenomena, and not followed by scaling. When they occur, as is frequently 
the case, as the first stage of various inflammatory affections they belong to the 
following class. It includes the hyperemias, anemias, cedemas, and hemorrhages of 
the skin. 

HYPEREMIAS. 

These are diffused or circumscribed reddenings of the skin due to the presence 
of an abnormal quantity of blood in its vessels. They are dependent on circulatory 
disturbances of vasomotor origin. They appear as spots or patches of varying size, 
discrete or confluent, and ranging in color from a delicate pink to a dark, purplish 
red. It is characteristic of them that their redness can be temporarily removed by 
pressure, showing that the congestion is located in the vessels of the superficial 
capillary plexus. We distinguish between acute or arterial hyperemia, with quick- 
ened circulation and heightened blood-pressure, and passive or venous hyperemia, 
with lessened pressure and slowed current. The arterial hyperemias include the 
various forms of simple erythema and roseola, though the latter is rather an exter- 
nal symptom of various internal circulatory disturbances than a distinct cutaneous 
affection. 

ACTIVE ARTERIAL HYPEREMIA. 

ERYTHEMA SIMPLEX. 

Synonyms. — Rose-rash, erytheme (Fr.), Hautrote (Ger.). 

Definition. — Various-sized, diffuse or circumscribed, non-elevated, reddish or 
purplish patches, disappearing on pressure. 

Symptoms and Course. — Erythema simplex appears as non-elevated spots or 

71 



72 illustrated skin diseases. 

macules, varying from pin-point size to large, irregular blotches. The entire 
body or only certain special regions may be affected. Their color may be faint 
red-pink, or deeper red, or bluish; and, not being elevated above the level of the 
skin, the spots cannot be distinguished by the touch. They are sometimes discovered 
only accidentally, since they are often unaccompanied by any subjective sensations 
whatsoever; but burning or itching may be present. They last for a few hours, 
days, or weeks, and they disappear without leaving pigmentation or being followed 
by desquamation. Special varieties of erythema simplex are the following: 

1. Erythema traumaticum, from continued pressure, as of tight bandages, or 
of the clothing, or from friction of any kind, or from the irritation of the finger- 
nails. It appears as a diffuse redness limited to the part involved, and usually of 
short duration ; for it disappears quickly when its cause is removed. If this does 
not occur, however, it may go on and become a dermatitis. 

2. Erythema solare, caused by the action on the skin of the ultra-violet rays of 
the sun and electric light. It occurs among the workmen in electric-light factories, 
and in tourists, more especially among the mountain-climbers who are exposed to 
the reflected light from the snow as well as to the direct rays. The exposed parts 
only are affected ; and the diffuse erythema that is set up disappears with fairly 
great rapidity when its cause is removed, but is apt to leave a lasting pigmentation 
behind. The irritant, if too long continued, may cause the erythema to pass into a 
true eczematous inflammation. 

3. Erythema caloricum is due to the action of a high or a low temperature upon 
the skin. It is more diffused and may affect parts covered by the clothing. 

4. Erythema venenatum. Here the irritant may be directly applied to the 
skin, or it may reach that organ through the circulation after having been taken 
into the stomach. The results of the local application of cantharides, mustard, 
pepper, etc., are examples of the first variety; and the erythematous medicinal 
rashes following the ingestion of quinine, belladonna, copaiba, and many other drugs, 
as well as those following the eating of oysters, shrimps, strawberries, etc., are ex- 
amples of the second. Personal idiosyncrasy plays an all-important part in this 
latter variety of erythema. 

5. Erythema symptomaticum. This occurs from various internal causes, and 
more especially during the course of the infectious diseases. It is a reflex from the 
central nervous system. Thus we have the erythema that occurs during sup- 
puration ; the erythema vaccinicum, so commonly seen in infants after vaccination ; 
the erythema variolosum that marks the suppurating stage of smallpox ; the ery- 
thema cholericum that appears in the convalescent stage of cholera ; and the erythe- 
mas of typhoid fever, of diphtheria, and of malaria. Erythema infantilis occurs in 
young children in connection with various febrile conditions, more especially with 
derangements of the gastro-intestinal tract ; from its short duration it is called also 
erythema fugax. In all these forms of the affection the macules are of fairly large 



NON-INFLAMMATORY CIRCULATORY DISTURBANCES. 73 

size, and by their coalescence frequently cover extensive areas of the skin with a 
diffuse redness. In erythema scarletiniforme, however, one of the commonest forms 
of the malady, the redness is punctate and closely resembles that of scarlet fever. 
It occurs after surgical operations, in uremia, septicemia, acute rheumatism, and 
many other conditions. When the spots are pea-sized and generally distributed over 
the body they have been termed roseola ; but this has been largely abandoned as a 
specific designation. 

Pathology. — The dilatation of the blood-vessels does not persist after death, and 
erythema simplex has practically no • pathology. The occurrence of permanent 
changes in the vessels and tissues would place the case in question in another class 
of diseases. 

Diagnosis. — The diagnosis of erythema simplex depends on its fugacity, the pos- 
sibility of causing the macules to disappear temporarily by pressure, and the absence 
of any signs of inflammation of the skin. The non-appearance of general symp- 
toms, of temperature, gastric and intestinal disturbance, coryza, etc., will prevent 
our confounding it with the specific exanthemata of the infectious diseases. 

Treatment. — This consists essentially in removal of the cause of the affection ; 
local treatment is rarely necessary. In erythema solare prophylaxis is the chief 
thing; Jessner recommends the application of quinine in solution or of glycerin to 
the exposed parts in those subject to it. In erythema scarletiniforme alkaline and 
bran baths are useful. Cold-cream and dusting powders (Nos. 15, 16, p. 58, No. 18, 
p. 61) are useful in all cases; alkaline solutions of borax or washing powder may 
be employed with benefit before they are applied. 

PASSIVE VENOUS HYPEREMIAS. 
LIVEDO. 

Definition. — A circumscribed or diffused dark, bluish-red discoloration of the 
skin, disappearing on pressure. 

Symptoms and Course. — The affected skin is cold, and is either uniformly dis- 
colored or mottled with bluish or purple spots removable by pressure. If too long 
continued, permanent dilatation of the veins, oedema, blood-extravasations, and even 
local gangrene (decubitus) may occur. The subjective symptoms are coldness of 
the part, with formication, prickling, and other disturbances of sensibility. The ex- 
tent of the livedo depends on the size and the situation of the vessel affected ; the 
smaller and the nearer the periphery it is, the less its size. A central venous ob- 
struction or one affecting one of the larger vessels gives rise to the general lividity 
known as cyanosis, a condition whose discussion belongs to the domain of general 
medicine. 

Pernio or chilblain is a variety of livedo. It appears as dusky-red, livid patches 



74 ILLUSTRATED SKIN DISEASES. 

of skin on the fingers, nose, toes, heel, or external border of the foot, and is seen 
most often in children and in old persons with poor circulations. Subjectively 
there is tenderness, itching, and burning; and the local process may go on to vesicu- 
lation, ulceration, and even superficial sloughing. 

Etiology. — The obstacle to the venous reflux which causes the passive conges- 
tion is usually mechanical in its nature. Paralysis of the vessel or disease of ils 
walls, thrombosis, embolism, or pressure, as by the bed or a tumor, etc., are the 
usual causes. 

Treatment. — This consists, above all, in the removal of the cause of the hypere- 
mia, if it can be found. Bandages may be employed to support the dilated veins, 
and elevation of the part affected will favor the return flow of blood through the 
veins. Massage and friction of the part are useful. Ergot is of some benefit to 
stimulate the muscular structure of the vessels. 

In the treatment of chilblains we must attempt to stimulate the stagnant circu- 
lation by frictions with camphorated oil or linimentum ammoniac, combined with 
brisk exercise and a suitable and warm clothing of the part affected. Iodine oint- 
ment, or the tincture of iodine, preferably discolorized by the addition to it of half 
its amount of aqua ammonia, is a useful application, as is also the ointment recom- 
mended by Sack (No. 28, p. 74). If the surface is broken and ulceration has oc- 
curred, boracic-acid ointment (No. 29, p. 74) can be employed. 

No. 28. Sack's Camphor Ointment. No. 29. Boracic-acid Ointment. 

R Balsam. Peruv. . . 1 part R Ac. boric. ... 1 part 

Camphor, trit. . . 2 parts Adip. lanae ... 3 parts 

01. amygdal. . . . 16 " Adip. suillis ... 4 " 

Adip. lanae 

Aq. rosae . . aa. 20 " 

ANEMIAS. 

General anemia of the skin, due to the blood-changes of excessive hemorrhage, 
anemia, chlorosis, leucemia, etc., is a symptomatic affection whose consideration 
belongs to general medicine. Circumscribed anemia, characterized by blanching of 
the skin, decrease of temperature, and cold sweat, may occur from spasm of the 
cutaneous vessels, or from their occlusion by an embolism or through stretching. 
None of these conditions causes dermal changes of sufficient importance to notice 
here. 

CEDEMAS. 

Diffuse and generalized oedema of the skin or anasarca occurs as a symptom in 
various internal diseases. Of the circumscribed cedemas, urticaria and prurigo de- 
mand our attention. 




COPYRIGHT BY E. B. TREAT 4 CO. , N. Y. 



PHOTOGRAVURE 4 COLOR CO., N. Y. 



URTICARIA 

PLATE II 






Synom, . 
Definition,- 
or reddish w 

Symptoms and 

ache, an 
skin, th 

aa) 
of a redd i- 
ble 
sting of th 

is, from 
the common n 
rived. Th< 
ing from on 
they disappeai 
leaving 
maj 

•o cover a ; 
they are never 
the 
mucosje are not exempt 

tract m 

ritant mate 
it. And while ■' 
and disapp' 
the dise 

r ions and 
A 

coal esc 

- 









i 






NON-INFLAMMATORY CIRCULATORY DISTURBANCES. 



75 



URTICARIA. 

Synonyms. — Hives, nettle-rash, Ncsselcmsschlag (Ger.), urticaire (Fr.). 

Definition. — An eruption characterized by the appearance of ephemeral white 
or reddish wheals, accompanied by intense pruritus and burning. 

Symptoms and Course. — The outbreak of an attack of urticaria is frequently 
ushered in by symptoms of gastric disturbance, anorexia, nausea, malaise, head- 
ache, and a moderate fever. Then, preceded perhaps by burning and tingling of the 
skin, there suddenly appear wheals, firm, circumscribed, convex elevations of the 
skin, usually oval or rounded in shape and 
of a reddish or whitish color. They resem- 
ble very closely the lesions caused by the 
sting of the common nettle, the Urtica 
urens, from which both the scientific and 
the common name of the disease are de- 
rived. They are always ephemeral, last- 
ing from one to a number of hours ; and 
they disappear without desquamation, 
leaving no trace upon the skin. They 
may be few in number, or so numerous 
as to cover a great part of the body, but 
they are never symmetrical. Any part of 
the integument may be affected, and the 
mucosae are not exempt ; the mouth, phar- 
ynx, air-passages, and gastro-intestinal 

tract may be involved, as is shown by the dyspnoea and vomiting that not infre- 
quently precede the outbreaks of cutaneous urticaria caused by the ingestion of ir- 
ritant materials. It occurs at all periods of life, but children are especially prone to 
it. And while the individual lesions are extremely fugacious, coming out suddenly 
and disappearing with almost equal rapidity, successive recurrent attacks may make 
the disease a chronic one if the irritation that causes it continues to act. The wheals 
sometimes occasion burning and tingling; but itching is the prominent subjective 
symptom, and it is usually so severe that the patient's body is marked with exco- 
riations and scratch-marks long after the individual wheals or the whole eruption 
has disappeared. 

A number of subvarieties of urticaria may be mentioned. Thus we have 
urticaria annularis when the wheals occur in rings ; urticaria gyrata and urticaria 
figurata when they appear as irregular circular or crescentic forms due to the 
coalescence of adjacent lesions. Occasionally the wheals are red, giving us urti- 
caria rubra; more frequently the white form, urticaria alba, is present. When 
the wheals are very large, perhaps equaling a hen's egg in size, we have urticaria 




FlG. 33. — Urticaria gyrata. 
From a photograph in the author's collection. 



76 



ILLUSTRATED SKIN DISEASES. 



tuberosa or gigantica. Urticaria chronica differs from urticaria acuta, as before 
said, only in the appearance of successive lesions for a long period of time. More 
important are the following varieties: 

1. Urticaria papulosa, the equivalent of the lichen urticatus of the older writers. 
This occurs in ill-nourished children with faulty digestions, and is a combination of 
the features of the wheal and the papule. The wheals are pea- to bean-sized, and 
are accompanied by intense itching. The child uses its finger-nails freely, and the 
torn papules tipped with blood-crusts, with the excoriations and pustules due to 
secondary infection, may remain long after the original lesion has vanished. 

2. Urticaria vesiculosa and urticaria bullosa are rarer, especially the latter. 
Here the oedema is sufficient to cause an accumulation of fluid under the epidermis, 

so that the wheal is tipped 
with a vesicle or a bleb 
The affections may even be 
mistaken for herpes or pem- 
phigus if seen after the oede- 
ma has subsided. 

3. Urticaria factitia is ; 
form of the malady that ma\ 
be excited at will in cases 
where there is excessive 
irritability of the cutaneous 
nerves. The application of 
any irritant to the skin causes 
the appearance of a wheal 
corresponding in shape and 
extent to the dermal area in- 
volved. The scratch of a 
finger-nail results in a white 
stripe, that turns first red, 
then white again, and finally 
develops into a regular urti- 
carial wheal. 

4. Urticaria hemorrha- 
gica, called also purpura urti- 
cans, where there is an effu- 
sion of blood as well as serum 

from the vessels, appears as a wheal with a hemorrhage in its center. An ecchy- 
mosis is left behind when the urticaria disappears. 

5. Urticaria pigmentosa is a rare form of the disease, cases of which have been 
described by Morrow and others. It is an extremely chronic form, the wheals be- 




Fk;. 34. — Urticaria factitia. 
From a photograph in the author's collection. 



NON-INFLAMMATORY CIRCULATORY DISTURBANCES. 



il 



ginning in early or even in intra-uterine life ; they are very persistent, and brown- 
ish red in color ; and they leave pigmented spots behind. 

Etiology. — Urticaria is due to disturbances of the vasomotor nerves, occurring 
either directly or by reflex action, giving us the idiopathic and the symptomatic forms 
of the disease. Such disturbances occur from a 
great variety of causes. Idiopathic urticaria is 
caused by the bites and stings of insects, mosqui- 
tos, bedbugs, lice, bees, wasps, etc. Leech bites, 
nettle stings, and contact with jellyfishes will 
also cause it. Direct mechanical violence will 
occasion its appearance, as will also certain medi- 
cinal substances. Symptomatic urticaria is the 
form most frequently met with, and is commonly 
dependent on digestive disturbance. Among the 
things that cause it are lobsters, clams, and vari- 
ous kinds of fish ; strawberries, gooseberries, and 
other fruits ; cucumbers, mushrooms, oatmeal, 
peas, beans, garlic, salad, etc. ; beer and alcoholic 
beverages. Sausage seems to be an especially 
frequent cause ; and Singer found that in many 
of these cases there was a marked increase in 
number of the normal bacteria of putrefaction of 
the lower intestine. Various medicines used in- 
ternally, as the balsams, arsenic, salicylic acid and 
the salicylates, quinine, chloral, opium, turpen- 
tine, and the iodide of potassium, will cause it. 
Moral emotions, shame, fear, and anger, some- 
times provoke an attack. Urticaria also occurs 
frequently in the course of rheumatism, purpura, 
prurigo, and pemphigus, and in the prodromal 
stages of the acute exanthemata. 

Sometimes no efficient cause for the urticaria 
can be found, more especially in the chronic 
cases. Personal idiosyncrasy performs an all- 
important part in its causation, and substances 
that give no trouble at all to most people invari- 
ably cause an attack of urticaria in those suscep- 
tible to their noxious influences. 

Pathology. — The pathology of urticaria, as found by Neumann, Vidal, and 
others, consists simply in a circumscribed oedema marked by serous effusion into the 
papillary body and the rete. Under the influence of the vasomotor nerves there 




Fig. 35.— Urticaria pigmentosa. 1 

Professor Elsenberg's case, Warsaw, Russia. 



IS 



ILLUSTRATED SKIN DISEASES. 



occurs capillary spasm, followed by paralytic dilatation and transudation of serum. 
The white color of the center of the wheal is caused by the greater pressure of the 
effusion at that point. 

Diagnosis. — Urticarial wheals when present are usually too characteristic to be 
mistaken for anything else. The points to be noted are the rapid appearance, the 
short duration, the itching and stinging, the rapid subsidence without desquama- 
tion, and the possibility of producing an urticaria factitia by irritating the skin. It 
can be distinguished from scabies by the absence of burrows and the non-involve- 
ment of the finger-clefts and other characteristic localities ; but it must not be for- 
gotten that it sometimes occurs in conjunction with that disease. In erythema sim- 
plex the patches are larger, more diffuse, and have no whitish centers. When the 
urticarial wheals coalesce, especially upon the face, the condition may resemble an 
erysipelas ; but the itching, evanescence, absence of a definite point of origin and 
of constitutional symptoms will serve to prevent mistake. 



No. 30. Saline draught. 



fy. Magnes. carb. 
Magnes. sulph. 
Aq. menth. pip. 



i part 
2 parts 
16 " 



No. 32. Menthol Capsules. 

fy Menthol .... 
01. amygdal. 

In caps, gelat. 



g«. 4 



No. 31. Atropia Pills. 

5: Atropia sulph. . . gr. yi 

Glycerin 

Aquae . . . . . aa. 3i 
Gum. tragacanth. . . . q. s. 
M., et ft. pil. No. 20. 



No. 33. Saalfeld's Menthol Lotion. 



fy Menthol 
Alcohol 



5 parts 

100 



No. 34. Carbolic Spirit. 



fy Ac. carbolic 
Alcohol . 



3 parts 
ioo " 



No. 35. Chloral Lotion. 



# Chloral 

Aq. laur. cer. 
Aq. dest. 



3 parts 
5o '* 
200 " 



No. 36. Chloral- Camphor Ointment. 



fy Chloral 
Camphor. 

Misce, et adde 
Glycerin. 
Ungt. simpl. 



aa. 1 part 

2 parts 
16 " 



Prognosis. — The acute form of the disease always gets well in a few days ; but 
the prognosis of the chronic form depends on the possibility of ascertaining and 
removing its cause. The papular urticaria of children is frequently a very obstinate 
malady, getting better in the winter, but recurring during the warm weather. 

Treatment. — The treatment of urticaria in its more refractory varieties is entirely 



NON-INFLAMMATORY CIRCULATORY DISTURBANCES. 79 

empirical. For the acuter and fugacious forms it suffices to find out and remove 
the cause. If, as is usually the case, it is located in the gastro-intestinal canal and 
has not yet left the stomach, a mild emetic, ipecac or mustard, is sufficient. This 
should be followed by a saline cathartic (No. 30, p. 78) or one of the mineral waters. 
The bowels being thus regulated, they should be kept in order Math small quantities 
of rhubarb and soda; and salol in doses of 5 grains may be administered several 
times daily with advantage. 

The treatment of the more chronic forms of urticaria is often a difficult and 
perplexing task. The underlying cause is frequently undiscoverable or irremovable. 
If rheumatism or gout is present the alkalis and colchicum are in order. Any 
concomitant disease of the internal organs, and more especially of the uterus, must 
be treated. Of the internal remedies, atropia, pilocarpine, menthol, and arsenic are 
the most useful. Atropia is recommended by Schwimmer in doses of ^20 °f a 
grain (No. 31, p. 78). Arsenic may be given in the form of the Asiatic pill (No. 6, 
p. 46), or as Fowler's solution, 4 to 10 drops in water three times daily. Joseph 
reports good results from the use of menthol (No. 32, p. 78). Pilocarpine is rec- 
ommended by Pick. The bromide of potash in large doses has accomplished good 
results in my hands ; and so have the salicylate of sodium, 1 to 2 drams daily, anti- 
pyrin, 15 to 45 grains daily, and the iodide of potassium, 15 to 90 grains daily, in 
those of others. 

Local treatment is of great importance, for the patients demand relief from the 
intolerable itching. This can be accomplished by dusting the surface freely with 
flour, or by the application of compresses wrung out in cold water. Any of the 
antipruritic lotions and powders recommended for pruritus may be useful (Nos. 11, 
12, p. 56, No. 17, p. 61, No. 27, p. 70). Alkaline, bran, or starch baths are service- 
able. Sponging the surface with vinegar and water or with a strong solution of 
baking-soda is valuable. Saalfeld recommends menthol in alcoholic solution (No. 33, 
p. 78) sprayed or dabbed on the affected parts. Carbolized alcohol (No. 34, p. 78) 
may be employed. Finally, chloral in the form of a lotion (No. 35, p. 78), or together 
with camphor as an ointment (No. 36 p. 78), is one of our most efficient antipruritics. 

Intractable cases are sometimes benefited by change of air, a sea voyage, or 
a course of mineral waters at Saratoga, Vichy, etc. 

PRURIGO. 

Synonyms, — Juckfleckte (Ger.), strophulus prnrigineux (Fr.). 

Definition. — A chronic affection characterized by the appearance of small, pin- 
head-sized, whitish or pinkish resistant papules, with general thickening and pig- 
mentation of the skin and intense pruritus. 

Symptoms and Course. — This malady, first differentiated and described by the 
elder Hebra, while fairly common in Austria and certain other parts of Europe, is 



80 



ILLUSTRATED SKIN DISEASES. 



extremely rare in England and in this country. A few American cases have, how- 
ever, been reported by Wigglesworth, Campbell, and others, and it is probable that 

the milder forms of the dis- 
ease occur here with greater 
frequency than is generally 
recognized. 

The malady always begins 
during the first or second year 
of life, making its appearance 
as an urticaria most commonly 
of the papular variety, lichen 
urticatus. Sooner or later 
there appear small, millet- 
sized, deep-seated, firm pap- 
ules covered with normal skin. 
They occur first on the exten- 
sor surfaces of the limbs ; the 
trunk may be invaded later; 
but the palms, soles, and face 
are always exempt. The in- 
ner surfaces of the joints are 
also unaffected. The papules 
may be quite colorless, so that 
they are hardly visible, or 
they may have a faint rosy 
tint ; but they can always be 
readily felt, and the skin in a 
well-developed case feels like 
the surface of a nutmeg- grater. 
After they have existed for 
some time the skin becomes 
markedly thickened, its furrows are exaggerated, and a brown discoloration due to 
blood-pigment replaces the normal hue of the integument. The neighboring lym- 
phatic glands enlarge, forming the so-called "prurigo buboes." 

Itching is the predominant subjective symptom, and has given a name to the 
disease. The impetus scabendi is so intense that resistance to it is out of the 
question. The patient must scratch, no matter where he is ; and he tears off the 
tops of the papules and lacerates his skin in the attempt to relieve himself. Hence 
arise excoriations, blood effusions and crusts, and inflamed areas, secondary appear- 
ances that may almost mask the original disease. At night the itching is especially 
severe, and causes obstinate insomnia ; but the attacks come on at other times, and 




Fig. 36. — Prurigo. 
After Van Haren-Noman. 



NON-INFLAMMATORY CIRCULATORY DISTURBANCES. 81 

render the patient unfit for society, for marriage, and for most of the ordinary avo- 
cations ; they have even driven him to suicide. 

Once firmly established, the malady usually lasts for life, becoming worse dur- 
ing each winter season. But the cases vary much in severity, and we distinguish 
between prurigo ferox or agria, to which the above description more especially ap- 
plies, and the milder form of the disease, known as prurigo mitis. 

Etiology. — The cause of the disease is unknown. It was formerly supposed to be 
especially common among the poorest classes, where improper nutrition and faulty 
hygiene are the rule ; but later investigators (Joseph and others) have found it just 
as frequently among the healthy and the well nourished. 

Pathology. — The papules are due to exudation and cell-infiltration in the rete 
and the papillary body. The thickening of the skin that is so marked in old cases 
is due to increase of the corneous layer, and the pigment in the rete is greatly in 
excess of the normal amount. The erector muscles of the hairs are hypertrophied 
and the sweat-glands are enlarged, while the sebaceous glands are atrophied. 

Diagnosis. — The deep-seated, hard papules, irregularly distributed over the 
body and most numerous on the extensor surfaces of the limbs, and the beginning 
of the malady in early life, are characteristic points and will facilitate the diagnosis. 
Eczema has no characteristic nodules, is vesicular, pustular, moist, or crustaceous, 
and affects by preference the flexor surfaces. Pruritus is very common and also has 
no nodules or thickening of the skin, and no local lesion save from the scratch effects; 
it begins at any age and is quite indeterminate in its locality. Scabies has its favorite 
location on the hands and genitals, and has the characteristic burrows. In phtheiriasis 
the presence of the parasite and the absence of the papules will serve to prevent mistake. 

Prognosis. — Prurigo mitis is curable, and prurigo ferox can be relieved. The 
opinion of Hebra as to the absolute intractability of the disease is no longer held. 

Treatment. — Attention to the general health is of the greatest importance, and 
fresh air, exercise, change of scene, and regulation of the digestive and other func- 
tions must be the basis of our treatment. Children should sleep in tightly closed 
flannel night-garments, and their hands should be bound up if necessary. Iron, 
quinine, and more especially cod-liver oil are indicated. Of internal remedies 
ergotine in 3- to 15-grain and bromide of potassium in 15- to 90-grain doses are 
perhaps the most useful. Pilocarpine, either hypodermically or by the mouth, has 
done good in some cases. 

Externally, hot water and soft soap in abundance are necessary with any treatment. 
The naphthol method introduced by Kaposi is perhaps the best. A 3- to 10-per- 
cent. naphthol ointment (No. 37, p. 82) must be vigorously rubbed into the affected 
skin daily for from four to eight days ; meantime the surface must not be washed, 
and the patient can take a bath only when the peeling that results has set in. Pro- 
longed sulphur baths (for one half to one hour) taken several times weekly, and fol- 
lowed each time by the naphthol ointment (No. 37, p. 82) or a chloral-camphor salve 



82 ILLUSTRATED SKIN DISEASES. 

(No. 36, p. 78), are efficacious. Tar baths or painting the parts with tar spirit (No. 
10, p. 56) is recommended. Sulphur and tar, preferably in the form of Wilkinson's 
ointment (No. 38, p. 82), is a favorite remedy, as are frictions with cod-liver oil used 
persistently for long periods of time. 

No. 3/. Kaposi's Naphthol Ointment. No. 38. Wilkinson's Ointment. 

ft Naphthol . 
Sapo. virid. . 
Petrolati 



5 parts 


ft Sulphur, sublim. 




30 " 


01. cadin. 


aa. 4 parts 


60 " 


Cret. prsep. 
Sapo. virid. 


5 " 




Adipis . 


. aa. 16 " 



The intervening eczemas, dermatites, ecthymas, etc., must be treated appropri- 
ately. Since in any case the treatment must be long continued, it is well to change 
from one to another of the above from time to time. And, in view of the extreme 
chronicity of the malady and the great tendency to relapses, a careful toilet of the 
skin and attention to its hygiene must be persisted in for life. 

HEMORRHAGES. 

Under this heading we class the various affections in which blood is present in 
the skin outside its normal position in the vessels. This may occur through rupture 
of the cutaneous vessels (rhexis), the skin itself remaining intact or not, or through 
diapedesis, the serum and corpuscles exuding through the apparently unbroken ves- 
sel wall. In either case the effused blood forms a sharply limited discoloration, 
which is not removable by pressure, and which undergoes the characteristic hematin 
color-changes, red, purple, yellowish-green, and brown, before it is finally absorbed. 
It is situated either between the layers of the epidermis or more deeply in the co- 
rium and the papillae. When the spots are rounded, oval, or irregular, non-elevated, 
and from pinhead to finger-nail in size, they are known as petechise ; longer and 
narrower effusions are vibices ; larger, rounded, non-elevated patches are ecchy- 
moses; while ecchymomata are extensive, deep-seated, flat or raised tumors. 

Cutaneous hemorrhages occur from the most moderate traumatisms in those 
affected with hemophilia (bleeders). This is an affection whose etiology and pa- 
thology is unknown, but which seems to be hereditary, and which occurs in people 
apparently otherwise perfectly healthy. Hemorrhages occur in any one as the result 
of traumatism, and usually go on to absorption. In exceptional cases only do they 
cause a reactive inflammation with casting off of the necrosed parts. In both vari- 
eties rest, the application of cold compresses, and later massage is the appropriate 
treatment. A symptomatic and secondary dermal hemorrhage occurs in certain 
cutaneous diseases (pemphigus, ecthyma, parenchymatous dermatitis) and in some 
general diseases (pyemia, diphtheria, smallpox, etc.). 

In two affections, however, purpura and scurvy, cutaneous hemorrhage is the 
prominent and sometimes the only symptom. 




COPYRIGHT, BV F. B. TREAT & CO., N. Y. PHOTOGRAVURE A COLOR CO., N. Y. 



PURPURA 



PLATE V. 









Synonyms, 

Definition.— 

or purplish I 1 

Symptoms and Cou ura are 

sudder. app 
Fever, general 
and 

presence and 
four forms of tl ■ 

I. Purpura im 

are frequently dis 
pea- 
trunk and u] 
They sometime 
Purpura 
potassium, a 

the usual r< 

more 

diameter. I 

genito-i. 

hemorrhagei 

the 

of the eruption 

orifices may 

• 
li 



th 

size and 

■ 

head- to 

■ 

i 

hiae apt 

• natients 

both int 

e hemorrl 

h muo 

n. There i 

e frequent. The affecti< 
i often se 

■ 




: 



NON-INFLAMMATORY CIRCULATORY DISTURBANCES. 83 

PURPURA. 

Synonyms. — Blutfleckenkranklieit (Ger.), purpura (Fr.). 

Definition. — Purpura consists in the appearance of various-sized, flat or raised, 
red or purplish hemorrhagic patches, not disappearing on pressure. 

Symptoms and Course. — All the varieties of purpura are characterized by the 
sudden appearance of hemorrhagic spots in the skin of varying size and shape. 
Fever, general malaise, pains in the limbs and joints, gastro-intestinal disturbances, 
and gingivitis may or may not accompany the outbreak. In accordance with the 
presence and severity, or absence, of these concomitant symptoms, we distinguish 
four forms of the malady : 

1. Purpura simplex. Here the constitutional symptoms are very slight or ab- 
sent, and the hemorrhages small in size and comparatively few in number. They 
come on quite suddenly, often at night ; and, as they cause no inconvenience, they 
are frequently discovered only by accident. They appear as bright-red, pinhead- to 
pea-sized spots, occurring first and most abundantly on the lower extremities ; the 
trunk and upper extremities are more slightly affected, and the face remains free. 
They sometimes show a distinct tendency to become urticarial (purpura urticans). 
Purpura simplex has been seen after the use of quinine, salicylic acid, iodide of 
potassium, and other drugs, but its cause is frequently undiscoverable, and it occurs 
most commonly in healthy individuals. The malady is self-limited ; the spots undergo 
the usual retrogressive color-changes, and the affection ends in two to three weeks. 
Successive crops of eruption may, however, prolong it for some time. 

2. Purpura hemorrhagica, known also as morbus maculosus Werlhofii and land- 
scurvy. This is a much more serious malady, with marked general symptoms and 
more extensive hemorrhages. The fever is high and is accompanied by headache, 
anorexia, nausea, constipation, and pains in the limbs. The petechiae appear sud- 
denly, and are larger than those in the simple variety, being frequently an inch in 
diameter. Petechiae appear also in the nasal, buccal, bronchial, gastro-intestinal, and 
genito-urinary mucous membranes, and, the epidermis being thin and readily removed, 
hemorrhages are very liable to occur. In most cases the patients get well, though 
the disease may be prolonged for many weeks by the outbreak of successive crops 
of the eruption ; but the loss of blood both into the skin and through the mucous 
orifices may be so severe as to cause collapse and death. 

3. Purpura rheumatica or peliosis rheumatica. Here the hemorrhages into the 
skin itself are usually small, the mucosa are affected, and the joints are always 
involved, several of them being usually red, painful, and swollen. There is marked 
fever and lassitude, with gastro-intestinal derangement, constipation, colic, and 
vomiting. Hematuria and albuminuria are frequent. The affection appears epi- 
demically in the spring and autumn, and is often seen in conjunction with erythema 
multiforme and erythema nodosum, which has led some authorities to classify it with 
the polymorphous erythema, and others (Joseph) to regard it as an infectious disease. 



84 



ILLUSTRATED SKIN DISEASES. 



4. Purpura scorbutica or scurvy. This formerly common malady is now rarely 
seen, thanks to improved methods of hygiene and feeding. Growing anemia and a 
gradually increasing depression of the general health precede the appearance of the 
cutaneous hemorrhages, which may take the form of petechias, vibices, sanguineous 
bullae, ecchymoses, and ecchymomata : while intramuscular and subseral blood-effu- 
sions also occur. Slight inju- 
ries to the affected skin lead to 
gangrene and the formation of 
scorbutic ulcers, with spongy 
bleeding bases, and showing 
little tendency to heal. The 
danger of internal hemorrhages 
is not so great as in the other 
forms, but hematemesis does 
occur, as also albuminuria, 
hemorrhagicpleurisy, and per- 
icarditis, pneumonia, and in- 
flammations of the joints. The 
gingivitis that accompanies the 
affection is characteristic. The 
gums are swollen, soft, spongy, 
and covered with a dirty gray- 
ish coating. They bleed easily, 
and there is marked fetor ex 
ore. 

Etiology. — The cause of 
purpura is in many cases undis- 
coverable. It occurs, however, 
secondarily to certain blood- 
alterations, as in the specific 
fevers, typhus, typhoid, vari- 
ola, etc.; in snake-poisoning; 
after the use of certain drugs, 
as iodine, quinine, copaiba, bel- 
ladonna, mercury, and others ; 
in scurvy, leucocythemia, pernicious anemia, chronic kidney and cardiac disease. 
Personal idiosyncrasy undoubtedly plays a large part in its production. In purpura 
simplex there is most often no cause discoverable; the patients are often in the best 
of health. Purpura hemorrhagica is apparently dependent on bad hygiene and im- 
proper diet. Purpura rheumatica is related to erythema multiforme, and its cause is 
similarly obscure. Purpura scorbutica is probably microbic in origin, though faulty 




Fig. 37. — Purpura simplex. 
From photograph in the author's collection. 



NON-INFLAMMATORY CIRCULATORY DISTURBANCES. . 85 

nutrition and the want of fresh food, especially of vegetables, and the absence of fresh 
air furnish the necessary conditions for its development. It was formerly common 
on shipboard and in penal and other institutions where large bodies of men were 
kept under unhygienic conditions. 

Pathology. — The pathological process consists in a simple hemorrhage unattended 
by inflammation ; the blood is effused in the papillary bodies or in the subcutis, and 
the vessels from which it comes may or may not be ruptured. It forms a foreign 
body that is slowly removed by absorption. Lardaceous and inflammatory changes 
of the vessel walls have been noted in some cases, while in others thrombosis or 
embolism has been found. 

Diagnosis. — This is rarely attended with any difficulty. The sharply circum- 
scribed spots, unaffected by pressure, can hardly be mistaken. In purpura simplex 
there are no other symptoms. In purpura hemorrhagica the mucosae are affected 
and internal hemorrhages occur. The joint complications are characteristic of pur- 
pura rheumatica. Purpura scorbutica is readily recognized by the gingivitis com- 
bined with the cutaneous hemorrhages. Inflammatory spots differ from purpuric ones 
in their elevation, disappearance under pressure, and subsequent desquamation. 

Prognosis. — This varies with the variety of the disease. In general the less frequent 
and extensive the hemorrhages, and the less the general constitutional involvement, 
the better the prognosis. Purpura simplex always ends in recovery, though its course 
may be slow. Purpura rheumatica is a stubborn malady, and relapses frequently 
occur. Purpura hemorrhagica is a dangerous and treacherous disease, and it is im- 
possible to foretell its termination. In scurvy the prognosis is also doubtful. 

Treatment. — This should be directed to the cause when that is ascertainable. 
Absolute rest in bed is essential in all but the mild cases. The patient should be 
kept very quiet, and care be taken that he obtains sufficient sleep. The diet should 
be mild and composed chiefly of milk. Alcohol in moderation may be given, es- 
pecially if the pulse is weak. Of the internal remedies ergotine in 15- to 30-grain 
daily doses is valuable, as is also turpentine, I dram every three hours. Nitrate 
of silver in doses of £ to ^ grain, or the tincture of the chloride of iron in full doses, 
may be tried. In the rheumatic form cold and anodyne applications should be 
made to the joints. Hemorrhages must be treated on general principles. Tam- 
ponade may be necessary if they occur from the nose ; ice pills or ice- water enemata 
when coming from the stomach or intestines. If collapse occurs, alcohol, camphor, 
and musk should be employed, and subcutaneous and intravenous infusions of 0.5- 
per-cent. saline solution may be required. In the scorbutic form prophylaxis by 
means of a proper supply of fresh vegetable food and a careful attention to hygienic 
details is the most important part of the treatment. Acids, and especially those of 
the vegetable variety, must be freely employed (lemons and similar fruits). The 
constitutional treatment is that suitable to anemia, and the various agents mentioned 
above may be employed for the purpose. 



CLASS III. 
INFLAMMATIONS. 



1 SUPERFICIAL INFLAMMATIONS AFFECTING THE CUTIS 

AND SUBCUTIS. 

THIS class includes some of the exanthemata, the dermatomycoses, the dermatites, 
catarrh of the skin (eczema), and the various forms of herpes, pemphigus, psoriasis, 
etc. All these maladies are characterized by a superficial inflammation of a transi- 
tory character, with circumscribed exudation and trifling tissue-changes. Many of 
them are caused by organisms, and it seems likely that a similar etiology will be 
finally established for others. By common consent some of them belong rather to 
the domain of general medicine than to dermatology ; and of these the cutaneous 
lesions alone will receive consideration. 

MORBILLI. 

Measles, Maseru (Ger.), rougeole (Fr.), is a specific contagious fever, character- 
ized by catarrh of the respiratory mucous membrane and a general papular eruption. 
After a stage of incubation lasting from nine to eleven days there occurs a catarrh 
of the mucous membranes of the bronchi, larynx, nose, and eyes, accompanied by 
a general febrile movement and lasting four days. Then the eruption appears, show- 
ing first upon the cheeks or forehead, spreading thence on to the neck, chest, breast, 
and back, and finally invading the extremities. In two or three days the body is 
covered, and by the time that the extremities are involved the exanthem has begun 
to fade on the parts first attacked. It appears as small, flat or slightly raised papules, 
which tend to coalesce and form characteristic circular or crescentic figures. The 
lesions, however, always remain more or less discrete, and they never form large 
diffusely reddened areas. Their color is a pink or red of varying intensity, depen- 
dent on the amount of the hyperemia; and this may be intense enough to occasion 
capillary hemorrhages on the surface of the papules, without, however, indicating 

86 





< 

z 

H 
< 

_J 

<r 
< 
o 

CO 



The i 

po; 

he al 



Ge 

anthem. 

the face . 






■ 








< 

z 

< 

cc 
< 

o 

CO 




INFLAMMATIONS. 87 

an especially serious form of the disease. The rash disappears by the fourth or 
sixth day, and with it the fever ; and it is followed by a small, fine desquamation, 
which may be so slight as almost to escape notice. We are ignorant of the cause 
of the disease. 

The contagium is present in the blood, the secretions of the mucosae, and the 
epidermic scales cast off during the process of desquamation. The dermic process 
consists of an acute hyperemia, with exudation into the vascular papillae of the corium, 
and congestion of the perifollicular plexuses of vessels. The skin eruption disappears 
after death. 

From rubeola, morbilli may be distinguished by its persistence for several days 
and the crescentic grouping of the papules. The diagnosis from scarlatina is im- 
portant, and is made mainly by the absence of the characteristic sore throat and the 
discreteness of the macular or papular eruption. From variola it may be distin- 
guished by the catarrhal symptoms, the persistence of the fever after the eruption 
is developed, the absence of vesicles and umbilicated pustules, and the discovery of 
the source of the contagion. The eruption of measles requires no treatment. 

RUBEOLA. 

German, French, or hybrid measles, Rotlieln (Ger.), rubeole (Fr.), is a conta- 
gious disease, marked by a slight febrile movement and a general macular ex- 
anthem. After an incubation of about two weeks there occurs a mild catarrhal 
conjunctivitis and rhinitis lasting two or three days. The eruption then begins on 
the face and scalp, and extends rapidly downward on to the trunk and extremities. 
It consists of pale rosy or reddish macules, varying in size from a pinhead to a large 
pea. By the fourth day it has disappeared, and it is not followed by any desquama- 
tion. Fever may be absent. It requires to be distinguished from measles, scarla- 
tina, and the syphilitic roseola. The macules differ from those of measles in that 
they are paler, more discrete, and not crescentic ; the duration of the disease is 
shorter, and its course is milder. In scarlatina the temperature is higher; the onset 
is marked with vomiting; the pharyngitis is characteristic; the rash appears first on 
the neck and breast, and is more of the nature of a diffuse erythema. The roseola 
of syphilis is accompanied by other evidences of the presence of lues, the sclerosis, 
polyadenitis, etc. Rubeola requires no special treatment. 

SCARLATINA. 

Scarlet fever, Scharlach (Ger.), scarlatine (Fr.), is a specific contagious fever, 
characterized by a macular and diffuse cutaneous exanthem, with involvement of the 
throat and the internal organs. 

After an incubation of from one to eight days, fever suddenly sets in, accom- 
panied by sore throat and often by vomiting. The red and swollen filiform papillae 



88 ILLUSTRATED SKIN DISEASES. 

projecting through the thickly coated surface of the tongue give to that organ a 
characteristic strawberry-like appearance. In from twelve to twenty-four hours 
after these initial symptoms the exanthem makes its appearance, beginning on the 
neck, and rapidly spreading over the chest, trunk, back, limbs, and the dorsal sur- 
faces of the hands and feet, the face remaining comparatively free. It consists of 
small pin-point- to pinhead-sized bright- red papules, disappearing on pressure, and 
in places so closely grouped together as to form a diffuse redness. This is most 
marked upon the trunk, and here the general color of the skin may be compared to 
that of a boiled lobster. The rash remains at its height for from three to four days ; 
it then begins to fade slowly, and in from four to ten days has entirely disappeared. 
Then follows a desquamation that is characteristic, being more complete and exten- 
sive than that of any other of the eruptive fevers. It may be furfuraceous or lamel- 
lar ; in the latter case the skin peels in large flakes, and complete casts of the palms 
and soles, or of the fingers with the nails, may be formed. 

Sometimes the eruption is slightly papular or even vesicular. In severe cases 
there may occur an extravasation of blood into the superficial layers of the skin, 
giving us the hemorrhagic form of the exanthem. 

The contagion of scarlatina is a fixed one, and is most active during the stage 
of eruption. It is present in the exhalations of the patient, as well as in the des- 
quamated scales, and may be carried from one person to another by an immune 
individual, or in the clothing, etc. It is probably a microorganism, or a product of 
microorganic growth ; but we are still entirely in the dark as to the actual patho- 
genic agent. The hyperemia and exudation are limited to the rete and the papillary 
layer of the corium, but the process is more intense than in the case of measles. 
The eruption disappears after death. 

Scarlatina requires to be differentiated from measles, rubeola, erysipelas, and the 
erythemata. The throat involvement, sudden onset, high fever, and the punctate 
rash beginning on the chest are characteristic of scarlet fever. In measles the erup- 
tion consists of larger macules arranged in crescentic form ; the face and especially 
the lips are first affected ; the symptoms of conjunctivitis and other catarrhs are 
marked; the disease does not begin with vomiting, and the desquamation is small 
and very fine. In erysipelas the smooth, glazed surface of the affected skin and the 
limited area involved should prevent mistake. The erythemata from digestive and 
other disturbances are as a rule unaccompanied by fever and are not followed by 
desquamation. Certain medicinal rashes, such as those occasioned by belladonna 
and quinine, may resemble scarlatina closely ; but they may be distinguished from 
it by their fugacity and by the absence of the fever and the throat symptoms. So 
far as the rash is concerned, any deviation from its normal course, too slow develop- 
ment, too rapid disappearance, or an undue prolongation, are of bad prognosis ; so 
also is a petechial or hemorrhagic eruption. 

The skin during the course of the disease should be regularly inuncted with 





UNVACCINATED GIRL. SECOND DAY OF ERUPTION. 



PUSTULAR AND EARLY DESICCATIVE STAGE. EIGHTH DAY OF THE ERUPTION 




TYPOGRAVURE. 



COPYRIGHT, 1905, BY E. B. TREAT & QO. , N. Y, 



SMALL POX IN STAGE OF DESICCATION AND D EC R USTATIO N . 
CASES OF OR. J.ftF. SCHAMBERG. 



VARIOLA. 



PLATE LX. 



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i 
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C»»l ■'•.vtJtBv. 



VARIOLA. 



PLATE 



INFLAMMATIONS. 89 

almond-oil, vaseline, or cold-cream; this is especially useful in the desquamative 
stage/since it not only protects the surface, but also tends to prevent the d ; ssemina- 
tion, through the atmosphere, of the scales, that are one of the main carriers of the 
contagion. 

VARIOLA. 

Smallpox, Slattern {Get), petite ve'role (Fr.), is a specific contagious febrile disease, 
characterized by the appearance of a papular, vesicular, and pustular eruption on the 
skin. After an incubation of from twelve to fourteen days the disease begins with a 
severe chill, followed by high fever, with frontal headache and pain in the back. These 
symptoms last for from two to three days ; and then, with a diminution or complete 
cessation of the fever, the eruption appears. It consists of minute red. spots, coming- 
first on the face around the lips and chin and on the neck and wrists. In two to 
three days they spread over the entire body. At first macular, the lesions soon 
develop into small, round, hard papules ; a day later they become vesicular, and by 
the fifth day the vesicles are fully developed, umbilicated, and surrounded by a red- 
dened, indurated, and tender base. They then become pustular, and the advent of 
suppuration is marked by a fresh rise of temperature, the secondary fever. By the 
tenth or twelfth day the pustules begin to retrogress by rupture or desiccation, and 
a peculiar and characteristic odor emanates from the patient. In a variable number 
of days the crusts and scabs fall off, leaving reddened areas that disappear, or per- 
manent cicatrices, in accordance with the involvement of the corium in the destruc- 
tive process. The number of pustules may be few, even less than a dozen, or there 
may be thousands of them; they may be discrete or confluent, and their contents, 
though usually pus alone, may, in the hemorrhagic form of the disease, be more or 
less mixed with blood. The mucosae are generally affected ; but here, on account 
of the thinness of the epidermic layer and the maceration to which it is subjected, 
erosions and superficial ulcerations take the place of the papules, vesicles, and pustules. 

Variola is eminently contagious, being transmitted in the volatile emanations of 
the patients. It is probably due to an organic cause, though its nature is as yet 
unknown. The secondary fever is septicemic, and is due to presence of the pus- 
cocci and their products. 

The prodromata and initial symptoms above enumerated, the papules developing 
into umbilicated vesicles and pustules, the cessation of the fever with the appearance 
of the eruption, and its subsequent recrudescence when suppuration begins, are char- 
acteristic. Nevertheless the diagnosis from measles, scarlatina, varicella, and the 
general pustular syphiloderm is often difficult. In measles we have the initial stage 
of catarrh of the respiratory and conjunctival mucosas, and the larger, flatter, discrete 
papules, never becoming pustules. In scarlatina there is the sudden onset, with 
vomiting and throat symptoms ; there is no remission of the fever as the eruption 
spreads, and the rash appears first on the chest and neck. In varicella the general 



90 



ILLUSTRATED SKIN DISEASES. 



symptoms are very slight; the vesicles are usually few, discrete, and filled with a 
clear serum ; they are rarely umbilicated, and there is no suppuration and but little 
scarring. The pustular syphilide is often accompanied by fever, and may greatly 
resemble smallpox. It can be distinguished from it by the absence of umbilication, 
its irregular spread, its frequent arrangement in crescentic or circular figures, the 
presence of other symptoms, and the history of the disease. 



VACCINIA. 

Cowpox, Kuhpocken (Ger.), vaccine (Fr.), is an eruptive disease of the cow, with 

a local lesion resembling that of variola at the site of inoculation, and occasionally 

with other general eruptions of varying form. 
When the inoculation material is taken from 
the human subject the course of the affection 
is more rapid and milder than when taken 
directly from the cow. In from three to ten 
days there appear small, red, indurated pap- 
ules on the inoculated area, which in two or 
three days more become vesicular and um- 
bilicated. Two to three days later they be- 
come purulent, and their base becomes hard 
and inflamed. With this there are moderate 
fever and mild symptoms of constitutional 
disturbance. Retrogressive changes and des- 
iccation then commence ; the inflammation 
disappears, and a hard, dark-colored scab re- 
mains on the site of the lesion and falls off 
by the third or fourth week. A reddened 
punctate cicatrice, which later turns white, is 
left behind. The amount of inflammation and 
destruction of tissue vary much in different 
cases. Not infrequently a so-called " rasp- 
berry growth " follows the vaccination, which 
is simply the exuberant dry granulation tissue 
resulting from the ulcerative process. 

A generalized eruption occasionally oc- 
curs at the same time and from the same cause. 
This is sometimes a roseola, running a rapid 
course, and disappearing in two days with a 
slight desquamation; or it may be a scarlatiniform reddening of the skin, or consist 
of a dusky mottling with patches like those of rubeola. Very rarely the eruption is 




Fig. 38. — Vaccinia. 

I Kiin photograph by the author. 




VARIOLA. 




TYPOGRAVURE. 



COPYRIGHT BY E. B. TREAT 4 CO. , N. Y. 



MORBILLI. 






OCCU: 

and child! 

fined 

the c 

but tl 

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VARIOLA. 







COFYRI^- ' TREAT i. CC 



MORBiLU. 



PLATE XII. 



INFLAMMATIONS. 



91 



vesicular, and it then resembles a beginning variola closely. Urticaria and erythema 
multiforme have been seen in connection with vaccinia. 



VARICELLA. 

Chicken-pox, Windpocken (Ger.), petite verole volante (Fr.), is a contagious febrile 
disease, characterized by the formation of vesicles filled with a clear serum. It 
occurs most often in infancy 
and childhood, and the gen- 
eral symptoms that accom- 
pany it are so slight that the 
patients are not usually con- 
fined to bed, and are often 
ignorant of the existence of 
the disease until the erup- 
tion appears. After fifteen 
to eighteen days of incuba- 
tion a mild fever occurs, and 
hyperemic macules appear 
scattered over the body, 
which rapidly become pap- 
ules, but never have the 
hardness that is so character- 
istic of variola. They soon 
develop into clear vesicles 
situated on slightly hyper- 
emic bases, but they rarely 
become umbilicated. They 
come in successive crops, and 
usually do not exceed pea- 
size. Twenty-four hours 
after their appearance des- 
iccation begins, and in five 
days the scales fall off. Scar- 
ring rarely results, for the corium is affected only where there has been much 
scratching. The mucosae are usually involved. The vesicles may be few or numer- 
ous, but they are very rarely confluent. 

The diagnosis between varicella and variola is often very important. Character- 
istic of the former disease are the occurrence in crops, the slight severity of the 
initial symptoms, the softness of the papules, and the absence of suppuration. In 
variola the invasion is severe, the papules are hard, and umbilicated vesicles and 




Fig. 39. — Varicella. 

From photograph by the author. 



92 



ILLUSTRATED SKIN DISEASES. 



pustules soon make their appearance. In measles there are the prodromal catarrhal 
symptoms, the larger flat macules, and there is no fluid in the lesions. Scarlatina 
has a severe invasion, sore throat, a punctate or confluent rash, and neither vesicles 
nor pustules. 

LICHEN PLANUS. 

Synonym. — Lichen ruber planus. 

Definition. — A chronic circumscribed inflammation of the skin, characterized by 
the formation of multiple, discrete or confluent, minute, purplish, waxy or scaly, 
umbilicated papules. 

Symptoms and Course. — Lichen planus occurs most frequently as a chronic and 
localized malady, the more acute and general form of the disease being rare. The 
site of the eruption is usually on the flexor surface of the forearms, especially around 




Fig. 40. — Lichen planus. 
From photograph of negress in the author's collection. 

the wrists, and on the backs of the hands and feet ; but other regions are not infre- 
quently affected, and it occurs occasionally on the palms, soles, and genitals. It is 



INFLAMMATIONS. 9.'! 

tare, however, on the face and scalp. It is frequently symmetrical. The lesions 
appear first as extremely minute papules of a characteristic dusky-red or purplish 
color, with a waxy glance, and sharply differentiated from the surrounding skin. 
Their sides are steep, and their shape is distinctly angular; while their tops are flat 
and marked with a central depression or capped with a minute scale. On the palms 
and soles the individual lesions may be hard to distinguish, the entire epidermis of 
the affected region being elevated and thickened, cracked in places, of a dusky-pur- 
plish hue, and covered with whitish scales. On the mucosas they appear as whitish 
flattened papules. They may be scattered or irregularly grouped. As they grad- 
ually enlarge to pea-size, adjacent papules coalesce, and thus extensive indurated 
and scaly areas are formed ; but the individual lesions do not increase beyond their 
original size. After persisting for a long time — months and years — they slowly 
undergo absorption, leaving atrophic pigmented areas behind. No vesicles or pus- 
tules are ever formed, nor are the nails or hair affected. 

The subjective symptoms are usually confined to a moderate itching, and it is 
only in the very extensive forms that it becomes severe. The patients are sometimes 
debilitated and run down by excesses or overwork, but not infrequently they are in 
excellent health. The malady occurs with about equal frequency in both sexes; it 
is seen at all ages, but is most frequent during middle life. 

Etiology. — The cause of the disease is unknown. It is not contagious. Most 
probably Kobner is right in attributing to it a neurotic origin. 

Pathology. — As Robinson has shown, the papules of lichen planus are caused by 
an inflammatory process in the papillae and the upper portion of the corium, shown 
by round cell-infiltration and other tissue-changes. In old papules the rete and the 
corneous layer are hypertrophied as a secondary change. The cell-infiltration is 
dense, presses on the vessels, and interferes with their nutrition ; and the consequent 
diapedesis of the red blood-cells is the cause of the purplish color of the lesions and 
the pigmentation after the atrophy of the papules. 

Diagnosis. — This rests on the peculiar shape, size, grouping, and appearance of 
the papules, as described above. Papular eczema, especially when situated on the 
forearm, may resemble lichen planus, but the papules are rounded and frequently 
have a little serum at their apices ; they are intensely itchy, run a rapid course, leave 
no pigmentation behind ; and other eczematous changes, excoriations, oozing, or 
crusting will probably be found somewhere on the skin. In the papular syphiloderm 
the lesions are round-topped and often arranged in crescentic or circular form ; 
they are generally distributed and more or less polymorphic; there is no itching; 
their color is reddish. Other signs of syphilis are probably present, and the disease 
responds to antiluetic treatment. In lichen scrofulosus the round papules are' grouped 
upon the trunk and are accompanied by no subjective sensations whatsoever. Fi- 
nally, in the papular psoriasis the lesions are pink, covered with abundant heaped- 
up scales, and are situated mostly on the flexor surfaces. 



94 ILLUSTRATED SKIN DISEASES. 

Prognosis. — This is favorable always. The disease is chronic and obstinate, but 
it tends to recovery. 

Treatment. — The general treatment must be tonic and roborant, since many of 
these patients are anemic and run down. Quinine, iron, and cod-liver oil are useful, 
together with regulation of the diet and general hygiene. Arsenic is, however, our 
main reliance, and it must be administered in full doses until the gastric oppression, 
the sense of constriction of the throat, etc., give warning of approaching intoxica- 
tion. It is best given in the form of the Asiatic pill (No. 6, p. 46), beginning with 
two daily, and gradually increasing the amount, or as Fowler's solution, 3 to 10 
drops in water three times daily. Joseph especially recommends the hypodermatic 
use of the drug, for which purpose Fowler's solution, diluted with twice the quantity 
of water, can be employed in the same doses as per orem. Kobner uses the arseniate 
of soda in the same way. The injections are painless, and the results are said to be 
brilliant. I have found that the preparation or mode of administration is of less 
importance than the persistence in the use of the drug for a long period of time. 

No. 39. UnncCs Carbolic- Sublimate Ointment. No. 40. Chrysarobin Ointment. 

$ Acid, carbolic. ... 20 parts fy Chrysarobin ... 1 part 

Hg. chlor. corr. 1 part Adip. lanse 

Ungt. zinci benzoat. . .500 parts Aq. rosae 

Adip. suillis . . . aa. 3 parts 

Locally, bran and alkaline baths are useful to allay the itching, or the various 
antipruritic lotions and salves (Nos. II, 12, p. 56, Nos. 33, 35, 36, p. 78) may be 
employed. Unna's carbolic-sublimate ointment (No. 39, p. 94) rarely fails to do 
some good, and should be tried in every case. Chrysarobin has been recommended 
by Herxheimer (No. 40, p. 94). 

LICHEN RUBER. 

Synonym. — Lichen ruber acuminatus. 

Definition. — A chronic inflammatory disease of the skin, characterized by the 
appearance of pinhead- to millet-seed-sized, firm, conical, red papules, coalescing into 
infiltrated scaly patches, and leading sometimes to marasmus and death. 

Symptoms and Course. — Lichen ruber is very rare in this country, and is by some 
authorities considered essentially identical with ordinary lichen planus. Commenc- 
ing on the trunk, the above-described papules spread over the entire body and even 
invade the mucosae. They remain stationary for a long period of time, and are not 
subject to retrogressive changes. New papules appear between the old ones, and 
finally the lesions fuse together into larger scaly masses. The integument of the 
entire body is then infiltrated, so that it is twice as thick as the normal skin ; it is 
dusky reddish brown in color, and rough to the touch like a nutmeg-grater, though 




COPYRIGHT BY E. B. TREAT 4 CO., N. Y. 



PHOTOGRAVURE 4 COLOR CO., N. Y. 



LICHEN PLANUS 



PLATE III 






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HEN PL* 



INFLAMMATIONS. 95 

no individual papules may be visible; and fissures appear at the joint flexure and at 
the natural folds. The nails become thickened, dark, and brittle ; the hairs lose their 
luster and fall out. 

The malady is an eminently chronic one, lasting for years and steadily advanc- 
ing. In its first stages the subjective symptoms are limited to a moderate itching; 
but when the whole skin is affected this becomes more severe, and emaciation, 
marasmus, and death, without any special lesion that we know of, may occur. The 
recognition and description of the disease are due to the elder Hebra, and his first 
fourteen cases ended fatally. As seen to-day, the lesions in the course of time 
become flatter and paler, and are finally absorbed, leaving pigmented scars behind. 
Vesiculation, pustulation, or ulceration does not occur. 

Etiology. — The cause of the disease is entirely unknown. It is most frequent in 
middle age, and is seen oftener in males than in females. 

Pathology. — This is still unsettled. All the layers of the skin seem to be involved 
in the chronic inflammatory process, but the cellular increase is most marked in the 
upper layers of the corium, in the papillae, and especially around the hair-sacs. 

Diagnosis. — The diagnosis can be difficult only on account of the rarity of the 
malady. The conical red papules, surmounted by a small scale, are characteristic. 
It must be differentiated from: I. A general papular psoriasis. This rarely covers 
the entire body, some portions being always unaffected ; there is a comparativelv 
large amount of heaped-up silvery scales; the flexor surfaces are most involved 
and the malady comes and goes, the efflorescences getting better and worse from 
time to time. 2. A general papular eczema. Here we have acute inflammatory 
papules of a vivid-red color, much itching, weeping surfaces, and a general poly- 
morphism. 3. Lichen planus, which has polygonal violaceous papules, with flat, 
smooth, waxy, and slightly umbilicated tops. 4. A general papular syphiloderm. 
This is never entirely universal ; it is grouped in circles or crescents ; and other 
symptoms of lues are almost always present. 5. Pityriasis rubra, in which the 
bright-red color, the apparent atrophy of the skin, and the non-involvement of the 
nails are characteristic. 

Prognosis. — This is good if the disease is properly treated ; relapses seldom 
occur. The bad prognosis of Hebra antedated the introduction of the arsenic treat- 
ment. 

Treatment. — Arsenic must be given in large and long-continued doses. If symp- 
toms of poisoning occur the dose must be diminished ; but the system soon accom- 
modates itself to the drug, and the doses can be increased again. The Asiatic pill 
(No. 6, p. 46) may be employed, commencing with two and going up to six or 
more daily ; or we may use Fowler's solution by the mouth, or hypodermically, as 
recommended in lichen planus (p. 94). Iron, cod-liver oil, and other tonics, with 
general hygienic measures, are also required. Locally, alkaline bran baths and the 
various antipruritic salves and lotions (Nos. 33, 34, 35, 36, p. 78, etc.) are useful. 



96 ILLUSTRATED SKIN DISEASES. 



DERMATOMYCOSES. 



The presence and growth of parasites, vegetable and animal, upon and amcng 
the epithelial layers of the skin and in the glandular structures that open into it, 
cause inflammation of that organ. This is mostly of a superficial character, and its 
consideration belongs under this heading. The vegetable parasites are fungi belong- 
ing to the class of the Hyphomycctcs, and they cause a series of affections known as 
the dermatomycoses. In some of them the morphology of the etiological factor is 
well established, but in others it is still a matter of doubt. All the various forms of 
ringworm are known to be due to varieties of the TricopJiytou tonsurans; pityriasis 
versicolor is caused by the Microsporon furfur; but Quincke, Unna, and Jessner 
have proved that several fungi may cause favus, and the exact nature of the parasite 
of pityriasis rosea and eczema marginatum is still undecided. The maladies that 
they cause are naturally all contagious; but the fungi require varying conditions for 
their growth, and hence their transmission is largely dependent on individual condi- 
tions, age, surroundings, and general health. 

The Hyphomycetes are fungous plants containing no chlorophyl and deriving 
their nourishment from organic substances. They consist of a network of double- 
contoured, branched threads or mycelium, constituting the thallus, from which spring 
upright branches known as the hyphae, containing the reproductive organs and 
spores. They are so similar in their size and general structure that the elder Hebra 
regarded them all as mere varieties of one parasite ; but both microscopical inves- 
tigation and clinical research have shown the erroneousness of this view. The par- 
asitic growth can be readily demonstrated in the epidermic scales and hair-structures 
after immersing them for a short time in a io-per-cent. solution of caustic potash. 

FAVUS. 

Synonyms. — Tinea favosa, dermatomycosis favosa, Erbgrind (Ger.), teigne fa- 
re use (Fr.). 

Definition. — A contagious parasitic disease of the skin, due to the growth in and 
upon it of the AcJiorion Scli'dnlcinii, characterized by the appearance of lemon- 
yellow cupped crusts, and leading to atrophy of the skin and its appendages. 

Symptoms and Course. — Favus is a rare disease in this country, almost all the 
cases that are seen here occurring in emigrants of the lowest classfrom Russia. Itoccurs 
most often on the scalp, but no part of the body is exempt, and Kaposi has even seen it 
on the mucosae. It begins as minute pinhead-sized reddish spots around the orifices of 
the hair-follicles, which soon enlarge and assume a yellowish tinge. The fungoid ac- 
cumulation grows until the fully developed, small, pea-sized mass, the scutulum, shield, 
or cup, is formed. This appears as a lemon-yellow disk firmly attached to the skin, 
and pierced in its center by one or more hairs. Its surface is concave or umbilicated, 
and its edges are raised ; and if it is forcibly removed it is found that its concave under 






INFLAMMATIONS. 



97 



surface is situated in a red and moist cup-shaped depression of the epidermis. It is 
formed of a series of concentric layers of a friable yellow material, which excavates 
and destroys the epidermic layers by its pressure. In the human subject this does not 
extend below the superficial layers of the skin ; but Sherwell has seen mice in which 
the bones of the cranium were perforated by the pressure of the growing cup. 

The single scutula may grow until they are V x of an inch or more in size. 
Adjacent ones then coalesce, and thus 
irregular, dirty, whitish-yellow, mortar- 
like masses are formed, and the charac- 
teristic cups are seen only at the edges 
of the patch, where the disease is pro- 
gressing. Left to themselves, the cups 
finally fall off, leaving depressed, circum- 
scribed, hairless, atrophic areas behind. 
More or less eczematous inflammation 
and suppurative folliculitis may accom- 
pany the disease, which in old cases may 
be very extensive. The hair in scalps 
affected with favus has a characteristic 
dusty, lusterless appearance, and feels 
dry and wiry to the touch. The pro- 
gressive pressure-atrophy finally leads 
to the entire destruction of the papillae 
and the glandular structures. The odor 
of favus is characteristic and mouse- 
like. 

Favus of the non-hairy parts is ex- 
tremely rare, and usually occurs in con- 
nection with favus capitis. The lanugo 
hair-follicles are more superficial than 
those of the scalp, and the parasite does 
not find as good a soil to grow on. The 
scutula are single or few in number, and 
are usually surrounded by a reddish, scab', 
or vesicular zone, looking very like ring- 
worm. The duration of favus corporis is 
generally short. 

Favus of the nails, onychomycosis fa- 
vosa, is very rare, and occurs from inoc- 
ulation of the finger-nails from scratching 
the head. Deep-seated yellowish spots, 




Fig. 41. — Favus corporis. 
Case of Professor Elsenberg, Warsaw, Russia. 



98 



ILLUSTRATED SKIN DISEASES. 



. ; 



due to the accumulation of the parasitic growth, appear in the nails, and they be- 
come dry, lusterless, furrowed, and raised. 

The malady is a very chronic one, usually beginning in childhood, and lasting 
for twenty years or more, so long as there are any hair-follicles left to be invaded. 
It sometimes, however, ends spontaneously. The subjective symptoms are limited 
to itching. 

Etiology. — The Acliorion Schonleinii, discovered by Schonlein in 1839, is the 
etiological factor of the disease, as has been proved experimentally by the inocula- 
tion of pure cultures. It grows on the skins of rabbits, cats, dogs, and mice, as well 

as on that of the human subject, and in a good 
many cases it originates in the household cat, who 
gets it from the mice. The parasite requires to be 
left undisturbed for two or three weeks before it 
obtains a firm hold on the tissues ; hence people 
of cleanly habits are not liable to contract it. It 
is far commoner in children than in adults. Only 
a single member of a family is attacked, as a rule ; 
but this is not always the case, and Duhring men- 
tions one instance in which ten cases were found 
in a single household. 

Pathology. — A moderate amount of inflamma- 
tion and cell-infiltration is caused by the growth 
of the parasite, which consists of an abundant net- 
work of mycelial threads and many spores. The 
mycelium is composed of flat threads about -gjf^ of 
an inch in diameter, divided by partitions into elon- 
gated cells. Inside these the oval spores or conidia 
develop ; but large masses of them are also found lying free. The fungus in its 
downward growth presses on the succulent rete-cells and causes their atrophy ; it 
also invades the hair and corionic papillae, and destroys them. Passing through the 
external root-sheath, it enters the hair and grows in the marrow substance. When 
the glandular structures are entirely destroyed the parasite no longer finds a suitable 
soil, and disappears. 

Diagnosis. — This is usually readily made. The destruction of the hair-follicles 
and the wiry condition of the hairs that remain ; the sulphur-yellow, round, concave, 
friable scutula pierced by hairs ; the depressed and atrophic but otherwise uninjured 
skin below them; the sparse, badly nourished, and wiry hairs that are left; the 
mouse-like odor; and, finally, the microscopic demonstration of the fungus in the 
crusts, will prevent error. When the disease is extensive the heaped-up mortar-like 
crusts may resemble the accumulated secretion of an impetiginous eczema ; but these 
latter are greenish yellow in color, and an inflammatory, moist, and weeping surface 




Fig. 42. — Aclwrion Schonleinii. 

x 400. After Joseph. 




COPYRIGHT, BY E. B. TREAT & CO., N. Y. 



PHOTOGRAVURE 4 COLOR CO., N. Y. 



FAVUS 



PLATE XI. 



Progx' 

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INFLAMMATIONS. 



99 



is found under and around them. Ringworm may in some cases resemble favus 
very closely, but there are no distinct cups or mortar-like masses or atrophy, and 
the frayed, nibbled-off hairs are characteristic. Microscopically the parasites in both 
diseases are too similar to be readily differentiated. 

Prognosis. — Favus, once deemed incurable, is not so rebellious to modern meth- 
ods ; but it is still very difficult to eradicate. In every case there is a more or less 
extensive permanent atrophy of the skin and destruction of the glandular structures. 
On the non-hairy parts it is read- 
ily removed, and sometimes dis- 
appears spontaneously. Favus of 
the nails is as obstinate as that of 
the scalp. 

Treatment. — This consists of 
the employment of epilation and 
parasiticide applications, and al- 
ways requires much patience and 
a long period of time. The hair 
should be cut short over the entire 
scalp, and a daily systematic re- 
moval of the affected hairs with 
the epilating forceps must go 
on simultaneously with whatever 
treatment is adopted. The crusts 
should be softened by binding 
cloths soaked in I per cent, naph- 
tholated oil (No. 41, p. 100) or 2 
per cent, salicylated or 5 per cent, 
carbolated oil on the scalp under 
an oilskin cap, until all the visible 
crusts can be removed with a spat- 
ula. The scalp is then thoroughly 

washed with the green soap tincture (No. 5, p. 43), and the resorcin-salicylic-sul- 
phur paste (No. 42, p. 100) is applied to the scalp. A 10- to 20-per-cent. pyrogallol 
ointment, or a 20-per-cent. oleate-of-mercury ointment, or the balsam of Peru, or 
a 10-per-cent. chrysarobin ointment (No. 40, p. 94) may also be employed. These 
are best first rubbed in with a stiff-bristle brush before being applied on cloths. 
The treatment must be persisted in for five or six days, and then several days can 
be allowed to elapse to see how many new scutula make their appearance. The 
course is repeated again and again until no new ones are seen. If the treatment 
irritates the scalp too much, it can be stopped from time to time, and a mild subli- 
mate ointment (No. 43, p. 100) used instead. 




Fig. 43. — Favus capitis. 
Case of Dr. J. F. Aitken. 



LOFC 



100 



ILLUSTRATED SKIN DISEASES. 



Favus of the body is readily removed by means of frictions with the tincture of 
green soap (No. 5, p. 43) or the use of the pyrogallol ointment (No. 44, p. 100). 




Fig. 44.— Hair-shaft and root-sheaths affected with favus. 
After Kaposi. 

Favus of the nails is obstinate, and the treatment must consist in scraping away with 
a knife as much as possible of the diseased structure, and applying mercurial plaster 
or the sublimate ointment (No. 43, p. 100). 



No. 41. Naphtholated Oil. 



R j3.-naphthol 
01. olivae 



1 part 
100 parts 



No. 42. Resorcin- Salicylic-Sulphur Paste. 

R Resorc. albissim. 
Ac. salicyl. 
Sulphur, depur. 
Amyli 

Zinc. oxid. . . . aa. 1 part 
Petrolati 5 P arts 



No. 43. Sublimate Ointment. 

1 part 

. aa. 500 parts 



No. 44. Pxrogallol Ointment. 



R Hydrarg. chlor. corr. 

01. amygdal. 
Adip. lanae 



R Pyrogallol 
Petrolati 



1 part 
20 parts 



INFLAMMATIONS. . 101 



TRICHOPHYTOSIS. 

The presence and growth in the skin of the Trichophyton tonsurans, discovered 
by Gruby and Malmsten in 1844, cause an inflammation of that organ, the clinical 
appearance of which varies in different portions of the body, and which has been 
given different names in accordance with the region affected. It was formerly sup- 
posed to consist of several distinct diseases, and the varieties do indeed differ so 
much that their symptoms, course, and mode of treatment require separate consid- 
eration. Certain general considerations are, however, in place here. 

Definition. — A contagious vegetable parasitic disease of the skin, caused by the 
Trichophyton tonsurans, and characterized by the presence of inflammation of the 
skin and destruction of its glandular appendages. 

Etiology. — The exact botanical position of the ringworm parasite is not yet set- 
tled, and Sabouraud and others have described several varieties in different forms of 
the disease. The consensus of opinion, however, is that there is but one parasite, 
and that the different forms are due only to different conditions of soil, etc. A 
secondary coccigenic infection is frequently added to the fungoid one, giving rise to 
deep-seated suppuration and abscess formation. It is eminently contagious, and 
much more common than favus. It affects, in its various forms, all ages and condi- 
tions, and is usually transferred from one patient to another through toilet utensils, 
articles of wearing apparel, etc. Dogs, cats, horses, and other animals are subject 
to ringworm, and are not very infrequently the sources of contagion. 

Pathology. — The trichophyton parasite consists of mycelium and spores, the 
former being double-contoured, branched threads, partitioned into cells, and similar 
in appearance, but more slender, than those of favus. The rounded spores are 
exceedingly abundant. It grows underneath the superficial layers of the corneous 
layer, and may invade the hair-bulbs and -shafts. It causes a superficial or deep- 
seated reactive inflammation, marked by scaling, redness, papulation, vesiculation, 
or, when pus infection has also occurred, follicular or more diffuse suppuration. The 
mycelium and spores can generally be readily demonstrated in the epidermic scales 
or the hairs after maceration in dilute liquor potassae. 

Prognosis. — This is good in all cases if appropriately treated. Care and labor 
and a long period of time are required, however, in many cases. 

TRICHOPHYTOSIS CAPITIS. 

Synonyms. — Tinea tonsurans, herpes tonsurans, ringworm of the head, scJicerende 
Flechte (Ger.), teigne tonsurante (Fr.). 

Definition. — Ringworm of the head, characterized by circular or diffuse, inflamed, 
scaly, or tumid patches, with diseased and broken-off hairs. 

Symptoms and Course. — Ringworm of the head is of fairly common occurrence 



102 



ILLUSTRATED SKIN DISEASES. 




Fig. 45. — Trichophytosis capitis. 

From photograph by the author. 

most of them are broken off within a line 
frayed and ragged ends looking like a 
coarse stubble covering the affected area. 

This is the usual form of the disease ; 
but sometimes there is associated with it 
a suppurative folliculitis of the hair-sacs, 
forming the condition known as kerion. 
The affected portion of the scalp is cov- 
ered with pustules ; there is considerable 
swelling; and crusts and exuding surfaces 
cause it to greatly resemble a pustular 
eczema. In very old cases, again, there 
are no circular areas, the whole scalp is 
covered with dry scales, the scattered hairs 
that are present are evidently diseased, and 
the entire appearance is that of a sebor- 
rhea or a chronic eczema. 

Etiology. — The common sources of 
contagion are the hats, hair-brushes, tow- 
els, and bed-linen used in common by in- 



in this country, and is almost always 
seen in children. It begins as a red 
macule, papule, or group of vesicles 
around the opening of a hair-follicle, 
which gradually enlarges into a round, 
grayish-red or slate-colored, slightly 
scaly patch. It may remain stationary 
at any size, and rarely exceeds an inch 
and a half in diameter. It may be 
single or there may be a number of 
spots ; adjacent patches may coalesce, 
and thus a large portion of the scalp, 
or even its entire area, may be affected. 
At the margins of the patches there are 
usually found inflammatory papules, 
vesicles, or pustules. The hairs are 
characteristically affected as the fungus 
grows down into the follicles and in- 
vades the shafts. The few long ones 
that remain look dull and lusterless, and 
are covered with a grayish dust ; but 
or two of the surface of the skin, their 




Fig. 46. — Trichophytosis capitis of long standing. 
From photograph by the author. 



INFLAMMATIONS. 



103 



fected and healthy children. The impossibility of enforcing the necessary hygienic 
measures in institutions where large numbers of children are herded together ex- 
plains its epidemic appearance. 

Pathology. — The parasite grows first in the epithelial layers of the scalp, but 
soon invades the hair-follicles and -shafts. The hair-bulbs are distorted and swollen, 
and when pulled out are found covered with a mass of white fungus. The shafts are 
filled with mycelium and spores, 
looking as if stuffed with fish-roe ; ' 7 v i 

and, as soon as they lose the sup- 
port of the follicle walls, split lon- 
gitudinally, and are broken off. 

Diagnosis. — This is readily 
made in typical cases, for the 
round, scaly patches and the nib- 
bled-off, frayed-out hairs are char- 
acteristic. But in the chronic and 
more diffuse cases it is sometimes 
very difficult. The malady often 
resembles a seborrhea ; and in 
other cases ringworm of the scalp 
must be differentiated from squa- 
mous eczema, alopecia areata, pso- 
riasis, and favus. Seborrhea of the 
head, causing baldness, is rare in 
children ; the scales are fatty, there 
are no broken-off hairs, and it is 
from the beginning a diffuse affec- 
tion, and does not commence as a discrete ring. The diagnosis from alopecia areata 
may also be difficult ; but in that disease there is little or no scaliness, no inflamma- 
tion, and few or no hair-stumps. Eczema squamosum is a diffuse affection, and the 
hairs are firm and unbroken. In psoriasis the scales are thick and silvery white ; 
there is no defluvium ; and patches of the disease will probably be found on other 
portions of the body. In favus the peculiar sulphur-yellow cups will always appear 
if the disease is left untreated for a week or so, and in old cases the presence of 
cicatricial tissue is characteristic. Finally, the microscope must be resorted to in 
doubtful cases. 

In many instances, however, and more especially in the chronic epidemics that 
occur in public institutions, the question of the presence or absence of ringworm is 
often a most difficult one to answer, since the large number of the cases renders in- 
dividual microscopic examination impracticable. Here Duckworth's chloroform test 
may be of value. A few drops are poured upon the affected area and allowed to 




Fig. 47.- 



-Hair and root-sheath of trichophytosis capitis. 
After Kaposi. 



104 ILLUSTRATED SKIN DISEASES. 

evaporate ; the mouths of follicles and the hairs that are affected turn yellowish 
white in color, and the scalp looks as if powdered with sulphur. The addition of a 
little oil restores it to its former appearance. 

Prognosis. — Many cases are very obstinate, especially in badly nourished children, 
and the treatment of ringworm of the scalp is still a very unsatisfactory chapter in 
dermato-therapeutics. Cases in which the characteristic appearances have vanished, 
but in which a persistent scaliness of the scalp remains, are not cured; a lens will 
reveal the frayed-out hairs, and the persistent use of the microscope will show that 
the parasite is still present. A cure is always a matter of months, and sometimes 
of years. 

Treatment. — Good food, fresh air, scrupulous cleanliness, and the use of tonics 
are important, in that they render the soil less suitable for the growth of the tri- 
chophyton parasite. The hair should be cut short to facilitate the recognition and 
treatment of affected areas. The scalp should be thoroughly washed at least twice 
a week with the green soap tincture (No. 5, p. 43), and a mixture of equal parts of 
alcohol and chloroform should be employed to remove the scales and fat before any 
parasiticide is applied. Epilation is required in many of the cases, the hairs remain- 
ing on the patch, and especially at its margins, being removed with the flat, broad- 
bladed epilating forceps. Thus the fungus-filled hairs are gotten rid of and the 
mouths of the follicles are opened so that the remedies employed can reach their 
depths. 

Of the many applications that are used corrosive sublimate is perhaps the most 
valuable. In a strength of 2 grains to the ounce of alcohol it should be thoroughly 
rubbed into the scalp with a brush or sprayed on it twice daily. It may also be 
used in ointment form, I to 250 or less (No. 43, p. 100). The compound tar spirit 
(No. 45, p. 104) and the sulphur-soap spirit (No. 46, p. 104) are favored by Wolff, 
Joseph, and others. The oleates, especially those of copper and mercury, are highly 
recommended by Shoemaker (No. 47, p. 105). A 5-per-cent. naphthol salve (No. 
48, p. 105) is valuable in very young children, and in recent cases chrysarobin (No. 
40, p. 94) is undoubtedly effective; but it must be used carefully, the eyes being 
protected and the head tightly covered. Blistering the surface with croton-oil, either 
pure or mixed with equal parts of olive-oil, and thus setting up a suppurative follic- 
ulitis, is required in very obstinate cases. The application should be made by the 
physician himself, care being taken to localize the action of the oil to the affected 
area. The part should then be poulticed and epilated. 

No. 45, Compound Tar Spirit. No. 46. Sulphur-soap Spirit. 

fy. 01. rusci . . . . .25 parts fy Sulphur, lot. . . 1 part 
Spts. vini Tr. saponis vir. . . .5 parts 

Ether, sulph. . . . aa. 40 " 

Spts. lavand. . . . .1 part 



INFLAMMATIONS. 105 

No. 47. Copper Oleate Ointment. No. 48. Naphthol Ointment. 



R 



Cupri s. hydrarg. oleat. . 


i part 


fy Naphthol 


01. olivae 


i " 


01. olivae 


Adip. lanae . 


io parts 


Adip. lanae 



i part 
2 parts 

20 " 



In any case, the patient should be as far as possible segregated, and care should 
be taken that no other child uses the brushes, towels, clothing, etc., without thorough 
disinfection with strong bichloride solutions. A cap should be worn all the time, 
and this should be either so cheap that it can be frequently renewed, or it should be 
fitted with a paper lining that can be changed every day or two. A modified treat- 
ment must be persisted in long after the disease is apparently cured. Two or three 
times a week a bichloride lotion or ointment (No. 43, p. 100, No. 49, p. 108) should 
be thoroughly applied. 

TRICHOPHYTOSIS BARBAE. 

Synonyms. — Tinea barbae, tinea sycosis, sycosis parasitica, dermatomycosis bar- 
bae, ringworm of the beard, barber's itch, Bartflcclite (Ger.), trichopJiytie sycosique 
(Fr.). 

Definition. — Ringworm of the beard, characterized by inflammation of the skin, 
with the appearance of papular, tubercular, and pustular lesions, and destruction of 
the hairs. 

Symptoms and Course. — Ringworm of the beard differs in appearance from the 
similar affection on other parts of the body in consequence of the anatomical pecu- 
liarities of its site. It begins as one or more pea-sized, or larger, circular red spots, 
with some papules and vesicles, and covered with branny scales, the hairs over the 
affected area being early loosened or broken off. Soon, however, if unchecked, it 
assumes the more characteristic form of the severer variety of the disease. The 
adjacent inflammatory areas coalesce, and deep-seated nodular lesions make their 
appearance. Large infiltrated masses are thus formed, of a deep purplish color, and 
tender and boggy to the touch. The subcutaneous connective tissue is undermined, 
and pus or a foul-smelling seropurulent secretion exudes from the orifices of the 
hair-follicles. This crusts upon the surface, and mats together the hairs over the 
whole swollen and infiltrated area. A condylomatous papillary growth from the 
surface of the mass frequently occurs, and the neighboring lymphatic glands are 
swollen and tender. The hairs over the affected area may fall out spontaneously, 
or they may be broken off close to the skin and frayed ; in any case, they lie entirely 
loose in their sheaths, and may be removed, as Anderson says, as readily as pins 
from a pincushion. Their sheaths are white from the mass of fungus material ad- 
hering to them. The process finally results in the complete destruction of the glan- 
dular structures of the skin, and atrophic, cicatricial, hairless areas are left behind. 



106 



ILLUSTRATED SKIX DISEASES. 



bearded face. Though acute fa its imrS iZ t^oT tueV^ ~ ? "" 
one, aud may ta for nl0 „ ths „ Rm^o™ To* ' !> ? " ChPOnic 

B sometimes present at the same time. POrtl °" s ° f the b ° d y 




Fig. 48.— Trichophytosis barba?. 

From photograph by the author. 

Trichophytosis barbs of the classical f™ ■ 
York a superficial form is in 1 "* * C ° mm ° n d, ' SeaSe - T " New 

which the maladvpre n \ air"" 1106 ; ^ ^ ^^ «* with, in 
worm of the body prance and runs the course of the ordinary ri„o- 

dar^^Lc Z ^^^T ^^ " ^ * * «~" 
^ead in the barber-shops ad not t ^ °?* The COnt ^ 0n is USUaU y 

the towels, lather-brush and he h f , raZ °''' " " ^^ SU ^ ed - bu t by 
frequently observed on ■ i t e It ' \ Z^" '' "* ^ the ™ d ™™ ^ are 

children affected with ringwonn. ^mmonly gotten from animals or 

ihe^d:^ been already described, grows in 

The perifollicular inflammation il ty"£ & ^ "* * *" ^ 



INFLAMMATIONS. 107 

Diagnosis. — The red scaly spots, deep tubercular infiltrations, broken-off hairs, 
the quick spreading, and the microscopic demonstration of the parasite are sufficiently 
characteristic. Nevertheless trichophytosis barbae requires to be carefully differen- 
tiated from two other affections of the beard which are included under the popular 
designation of barber's itch, viz., perifolliculitis barbae and eczema barbae. In peri- 
folliculitis the course of the disease is slower; it begins most frequently on the upper 
lip ; the hairs are only affected later, after suppuration of the follicles has set in ; 
there are no deep tubercular infiltrations or papillary growths ; the trichophyton is 
not present ; and the small, discrete pustules, each pierced by a hair, are character- 
istic. Eczema of the beard is also most frequent on the upper lip, and a catarrhal 
or suppurative rhinitis is often present ; it is an entirely superficial affection, with 
vesicles, serous discharge, and crusts ; the parasite is not present ; the hairs are not 
affected; no scar tissue results; and non-hairy parts in the neighborhood are usually 
involved. A papular syphiloderm of the bearded face may occasionally resemble 
ringworm ; but the circular arrangement of the tubercles, the ulceration, the absence of 
deep-seated suppuration and of the fungus, with the history, should prevent mistake. 

Prognosis. — These cases are often very rebellious. Left to itself, the process 
goes on until all the hairs of the beard are destroyed. 

Treatment. — In the superficial ringed form any of the parasitic applications (No. 23, 
p. 64, No. 34, p. 78, No. 38, p. 82) may be used. In obstinate cases it is sometimes nec- 
essary to have recourse to a strong sublimate spirit or lotion (No. 49, p. 1 08), which must 
be cautiously dabbed over the surface two or three times daily and allowed to dry. 
In the deeper-seated suppurative forms the hair of the beard and mustache must be cut 
close with the scissors ; shaving must not be resorted to, because it spreads the infec- 
tion to neighboring healthy parts. Epilation is required in every case. It can be done 
readily and painlessly, for the affected hairs are so loose in their sheaths that they come 
out with ease. It must be done systematically, an area of skin being cleared each 
day. The healthy portion of the beard should be protected from further infection by 
dabbing sublimate spirit (No. 49, p. 108) over it once daily. The affected part is then 
washed thoroughly with the green soap tincture (No. 5, p. 43), then with chloroform 
and Lassar's paste (No. 2, p. 43) or Wilkinson's ointment (No. 38, p. 82) or the 
tannin-sulphur paste (No. 50, p. 108), applied twice daily for several days, until irri- 
tation and peeling of the skin occur. Having thus removed the scales and a large 
quantity of the fungus, the part is ready for the parasiticide applications. 

Of parasiticides the most efficacious is perhaps the 10-per-cent. chrysarobin col- 
lodion (No. 51, p. 108), which must be applied to the part with a stiff brush twice a 
day for three or four days, and then stopped until desquamation occurs. There 
need be no fear of using chrysarobin on the face in this form ; it causes no trouble, 
save for a slight discoloration of the skin. The oleate of mercury, 10-per-cent. so- 
lution in oleic acid, or the copper oleate ointment (No. 47, p. 105) or the sublimate 
ointment (No. 43, p. 100) may also be used. 



108 ILLUSTRATED SKIN DISEASES. 



No. 49. Sublimate Spirit. No. 50. Tannin- Sulphur Paste. 

% Hydrarg. chlor. corr. . . i part $ Acid, tannic. ... 5 parts 

Spts. vini rect. . . . 500 parts Lac. sulph. . . . . 10 " 

Petrolati . . . . 50 " 
Zinci oxidi 
Amyli aa. 17.5 " 

No. 5J. Chrysarobin Collodion. 

$: Chrysarobini 1 part 

Collodion flexile . . .10 parts 

The abscesses must be freely opened, and the deep infiltrations are best treated 
by the application of the mercury-carbolic plaster mull, which has an excellent effect 
and quickly causes their resorption. Papillary growths must be scraped away, and 
the free use of the curette on the deep infiltrations after their incision removes large 
masses of fungus and greatly hastens their cure. The application of poultices, as 
recommended by some authorities, only promotes the growth of the parasite. 

TRICHOPHYTOSIS CORPORIS. 

Synonyms. — Tinea circinata, herpes circinatus, ringworm of the body, herpes 
circine (Fr.). 

Definition. — Ringworm of the general integument, characterized by macular, 
vesicular, papular, or squamous lesions of circular outline, with scaly or normal 
centers. 

Symptoms and Course* — Ringworm of the body in its milder varieties, with one 
to half a dozen lesions, is a common disease ; but the more chronic and generalized 
forms are rarely observed in this country. It begins as a small, circular, slightly 
raised reddish macule, sharply circumscribed, and removable by pressure. It spreads 
peripherically until it may attain the size of a large coin, and while the advancing 
margin remains red, the color of the center gradually fades into a pale yellowish 
pink. Fine branny gray scales cover the patch. Adjacent patches may coalesce, 
forming irregular circinate areas, and in rare instances concentric rings of parasitic 
growth may appear. This form, in which ringworm of the body always begins, is 
known as herpes tonsurans maculosus, and is most commonly found on the exposed 
parts of the body, where there is but little heat, moisture, and friction, as the face, 
neck, and arms. 

Occasionally a row of vesicles filled with a clear serum marks the edges of the 
patch, forming the variety known as herpes tonsurans vesiculosus. They soon dry 
up into fine branny scales. Where there is much friction and heat, as in the in- 
framammary region in stout persons, the parasitic growth is more abundant, and the 




COPYRIGHT BY E. B. TREAT & CO., N. Y. 



PHOTOGRAVURE AND COLOR CO., N. Y. 



TRICHOPHYTOSIS 



PLATE VIII. 



- 

Etiology.— - 

■ 

■ 




Dia 









i 




- ' ; 



HOPHYT 






INFLAMMATIONS. 



KM) 



formation of inflammatory papules gives us the variety known as herpes tonsurans 
papulosus. Finally, when there is much scaling, we have herpes tonsurans squa- 
mosus. In the chronic generalized cases the lesions are ill defined, irregular or con- 
fluent, and scattered over the surface 
of the body as reddish scaly spots. 

Ringworm of the body occurs espe- 
cially in the young, and is most com- 
mon at the seasons when the heat and 
moisture in the atmosphere are most 
favorable to fungus growth. It may 
disappear spontaneously in a few 
months or weeks, or it may last for 
years. There is a good deal of itching 
in some cases, and secondary scratch 
effects are not uncommon. 

Etiology. — Not all individuals are 
susceptible to ringworm infection, and 
the condition of the skin and of the 
general health are undoubtedly im- 
portant factors in its occurrence. It 
is rare in infants and in adults, and 
occurs most commonly in weak, ane- 
mic, and badly nourished children, and 
those that live in damp, unhealthy 
dwellings. It is often contracted from 
cats, dogs, horses, and cattle, and is 
very contagious. 

Pathology. — The presence of the fungus causes a more or less superficial eczema 
or dermatitis, with vesiculation, papulation, or scaling. Its location is in the corneous 
layers, and the lanugo hairs are not affected. 

Diagnosis. — In addition to the clinical characteristics above mentioned, the pres- 
ence of the parasite is readily demonstrated in ordinary cases under the microscope. 
In the chronic cases of disseminated ringworm the parasite is much more difficult to 
find. The malady requires to be differentiated from : I. Eczema, which has no sharp 
margins, and is rarely circular or clearing in the center, itches much more, and is 
much more frankly inflammatory. 2. Seborrhea, which on the chest and back often 
looks much like ringworm, having circular scaly patches with clearing centers; the 
greasiness of the scales and the almost entire absence of inflammation will serve to 
distinguish it. 3. Psoriasis, which frequently appears as rings with cleared centers, 
but which the abundance of the dried silvery scales, the absence of exudation, vesi- 
cles, or papules, and the characteristic location, will sufficiently distinguish. 




Fig. 49. — Trichophytosis corporis. 

From photograph by the author. 



110 



ILLUSTRATED SKIN DISEASES. 



Prognosis. — Ringworm of the body is readily cured, but relapses not infrequently 

occur and prolong the cases. 

Treatment. — The parasite is superficially placed, and has but a feeble hold upon 

the skin. After the removal of the superficial scales with the tincture of green soap 

(No. 5, p. 43), or by the use for a 
day or two of the pure green soap 
spread upon a piece of lint, the ap- 
plication of almost any of the ordi- 
nary parasiticides will suffice to re- 
move the fungus. Corrosive subli- 
mate in l-per-cent. solution may be 
dabbed on the patches once a day, 
and allowed to dry ; or the tincture 
of iodine, or carbolic acid in glyce- 
rin, 1 to 16, or the white precipitate 
ointment, may be employed. I 
prefer the chrysarobin collodion 
(No. 51, p. 108), painted over the 
patch every day or every other day. 
Kaposi's naphthol ointment is rec- 
ommended (No. 37, p. 82) by Las- 
sar. Tar or sulphur ointments (Nos. 
22, 25, p. 64) or Lassar's paste (No. 
2, p. 43) may be employed in obsti- 
nate cases. Morris's thymol-chlo- 
roform oil is also beneficial (No. 52, 
p. no). 

No. 52. Morris's Thymol- Chloroform 
Oil. 




Fig. 50. — Dermatomycosis flexurarum. 
From photograph by the author. 



fy Thymol. 
Chloroform. 
Ol. olivae 



1 part 
4 parts 
12 " 



Pityriasis rosea, described by Gibert as a special disease, is probably only a gen- 
eralized form of ringworm of the body. 



TRICHOPHYTOSIS CRURIS. 

Synonyms. — Eczema marginatum, dermatomycosis marginata, ringworm of the 
crotch. 

Definition. — Ringworm of the genitocrural region, characterized by the appear- 




TYPOGRAVURE. 



COPYRI3HT, 1905, BY E, B, TRfAT 4 CO., N, Y. 



ECZEMA MARGINATUM. 



PUATE LVII. 



Symptoms and Cot 










- 



. 



I 




E. B. T&- 



ECZF. 



INFLAMMATIONS. Ill 

ance of spreading, circular, discolored patches with inflammatory margins and grayish 
or brownish centers. 

Symptoms and Course. — Ringworm of the crotch is most common in hot and 
damp climates, but is not infrequently seen here. It occurs on the par-ts that are in 
contact, and therefore most exposed to the effects of heat, moisture, and friction. 




Fig. 51. — Pityriasis rosea. 
Case of Dr. J. F. Aitken. 

It is most frequent in the genitocrural fold, and spreads from thence to the inside 
of the thigh, the anal and suprapubic regions, the penis and scrotum being usually 
free. Much more rarely it affects the axillary and inframammary regions. It be- 
gins as a rounded, scaly, slightly raised reddish disk spreading peripherically and 
paling at the center. The margins are markedly inflammatory and are studded 
with papules and vesicles. The central portions may be reddened, moist, and eczem- 
atous, or pale and slightly discolored. Adjacent patches coalesce, and thus large 
symmetrical areas of the disease, with crescentic and sharply marked borders, are 
formed. Considerable thickening of the skin finally results. The itching is very 
intense, and scratch-marks and excoriations are common. The malady is a very 



112 



ILLUSTRATED SKIN DISEASES. 



chronic one, and may last for years; it shows no tendency to spontaneous healing. 
The hairs are never affected. 

Etiolojry.— The dependence of the disease upon the presence of the trichophyton 
parasite has been proved by Kobner, Pick, and Kaposi. The contact ot profusely 
sweating surfaces and the maceration of the skin that ensues seem to be necessary 
for its growth. 




FlG. 52. — Trichophytosis cruris. 
From photograph by the author. 

Diagnosis.— The crescentic patches with elevated brownish-red margins and dis- 
colored centers, the intense itching, and the location, are sufficiently characteristic 
The disease requires to be differentiated from an eczema intertrigo of the gemtocrural 
regions, which has a red, frankly inflammatory, and freely secreting surface, most 
inflamed in the center of the patch, an irregular, ill-defined margin, and vesicles and 
papules outside the area affected. 

Prognosis.— The malady is not very contagious, and men affected with it do not 
usually give it to their wives. Though curable, it is often very obstinate, and re- 
lapses frequently occur. 




COPYRIGHT BY E. B. TREAT * CO., N. Y. 



PHOTOGRAVURE & COLOR CO., N. Y. 



CHROMOPHYTOSIS 



PLATE XXIII 



Tre 

- 

- 
10- 

tpplied t tl •» 

to 
rem ish- 




No. 53 



or otr 

- 






Syr 






:^YTOS 









CHROMC 






INFLAMMATIONS. 



113 



r 



r 



Treatment. — After thorough preliminary washing with the tincture of green soap 
(No. 5, p. 43), Wilkinson's ointment (No. 38, p. 82) should be applied for several 
days, followed by naphthol in 5-per-cent. ointment (No. 48, p. 105) or in i-per-cent. 
spirit or oil (No. 41, 
p. 100). This is per- 
haps the best means at 
our command for the 
eradication of the dis- 
ease. Chrysarobin in 
10-per-cent. ointment 
(No. 40, p. 94) or as 
collodion (No. 51, p. 
108), applied to the 
patch once daily for 
several days, and the 
parts then allowed to 
remain without wash- 
ing for several days 
more, is also efficacious. 

The ichthyol-mercury ointment is employed by Wolff (No. 53, p. 1 13). Joseph rec- 
ommends that in obstinate cases the whole surface should be touched with a 10- 
per-cent. solution of caustic potash, followed by the application of a zinc paste (No. 
54, p. 113), and treatment completed by the use of Wilkinson's ointment (No. 38, 
p. 82). The menthol or carbolic spirit may be used to relieve the itching (Nos. 33, 
34, p. 78). 

No. 53. Ichthyol-Mercury Ointment. 

R Amnion, sulph-ichthyol. 
Ungt. hydrarg. amnion. 




Fig. 53. — Trichophytosis cruris. 
From photograph by the author. 



mt. 


No. 54. Zinc Paste. 


1 part 


R TeiT. silic. . . . 10 to 20 parts 


10 parts 


Ungt. zinci ox. . 80 " 



Prophylaxis must consist of frequent washing, followed by the free use of a zinc 
or other dusting powder (No. 18, p. 61). The parts should be kept separated by a 
pad of absorbent cotton, and a suspensory bandage should always be worn. 

CHROMOPHYTOSIS. 



Synonyms. — Pityriasis versicolor, tinea versicolor, dermatomycosis furfuracea, 
Kleienflechte (Ger.). 

Definition. — A vegetable parasitic disease, characterized by the appearance of 
yellowish or brownish slightly furfuraceous macules or larger areas, and caused by 
the growth upon the skin of the Microsporon furfur. 



114: 



ILLUSTRATED SKIN DISEASES. 




Fig. 54. — Microsporon furfur. 
x 600. After Joseph. 



Symptoms and Course. — Chromophytosis is a very common disease, more espe- 
cially in those suffering from phthisis or hyperidrosis. It begins as small pinhead- 
to pea-sized rounded macules, situated around the orifices of the hair-follicles. They 

are very slightly elevated, and are covered with 
minute grayish-white scales, which can be rendered 
more evident by scraping. Their color varies from 
light yellowish brown and buff to a deeper reddish 
tint ; they may be few in number or numerous, and 
in the latter case they frequently enlarge and co- 
alesce into irregular areas of varying size. They 
are found upon the covered portions of the body, 
most often on the chest, abdomen, and back ; the 
neck and the backs of the hands are rarely affected, 
and the face, palms, and soles are always free. Sub- 
jectively, slight itching is the only symptom. The 
malady occurs chiefly in adults, and is rare in chil- 
dren and the aged. Its duration is entirely indefinite ; it may last months or years. 
In exaggerated forms the entire trunk may be covered. 

Etiology. — Chromophytosis is caused by the growth on the skin of the Micro- 
sporon furfur, discovered by Eichstadt in 1846. The parasite does not grow on parts 
exposed tothe lightand that 
are frequently washed ; and 
lowered general nutrition 
and defective hygiene of 
the skin, more especially 
when combined with ex- 
cessive sweating, are the 
factors that favor its devel- 
opment. It is but very 
slightly contagious, and ex- 
amples of direct transmis- 
sion from sleeping together 
and using the same towels, 
etc., are rare. 

Pathology. — The para- 
site grows very luxuriously 
in the upper cells of the cor- 
neous layer, and the furfu- 
raceous scales are almost 

entirely composed of its mycelium and spores. The hairs are not invaded. The 
mycelium is very like that of the trichophyton, but slenderer, and the spores are 




Fig. 55. — Chromophytosis. 
From photograph by the author. 



INFLAMMATIONS. 115 

collected in groups or appear at the ends of the mycelial threads. The exact bo- 
tanical position of the parasite is still undecided. 

Diagnosis. — The sharply limited brownish spots, the slight scaling, and the char- 
acteristic location sufficiently distinguish the disease. The microscopic demonstra- 
tion of the parasite is readily made if a few of the scales are put on a slide with a 
drop of dilute liquor potassae. In chloasma there is no scaling and no parasite; it 
occurs on the uncovered parts, and cannot be removed by scratching. Seborrhea 
has an inflammatory margin of red papules; the scales are greasy and more abun- 
dant, and no parasitic fungus is present. A macular syphiloderm may occasionally 
resemble chromophytosis, but its color is more coppery, there is no itching and no 
parasite, and other symptoms of lues will almost certainly be present. 

Prognosis. — This is good, for the parasitic growth is easily removed. 

Treatment. — Prophylaxis consists in frequent bathing, together with the treat- 
ment of the hyperidrosis. The underclothing should be frequently changed, and, 
especially if it is of flannel, should be well sterilized by boiling before it is used 
again. 

Treatment of the disease itself consists in the thorough removal of the scales and 
superficial masses of the parasite by the free use of the tincture of green soap (No. 
5, p. 43) and hot water, after which any of the ordinary parasiticides may be em- 
ployed. Sulphur paste or ointment (Nos. 24, 25, p. 64) or Wilkinson's ointment 
(No. 38, p. 82) or naphthol in ointment or oil (No. 37, p. 82, No. 41, p. 100) may be 
used for from four to eight days, until scaling sets in, when a hot bath may be taken. 
The tar spirit (No. 10, p. 56) and the sublimate spirit (No. 49, p. 108) are also effi- 
cacious. The naphthol green soap spirit (No. 55, p. 115) is highly recommended by 
Joseph. I use the hyposulphite of soda as a lotion (No. 56, p. 1 15), and find it suf- 
ficient in almost all cases. One very obstinate and extensive case in my experience 
resisted all manner of treatment, but was finally cured by a course of prolonged 
sea-baths. 

No. 55. Joseph's Naphthol Green Soap Spirit. No. 56. Sodic Hyposulphite Lotion. 

R- Naphthol .... 5 parts R- Sod. hyposulphitis . . . 1 part 

Solve in spir. vini rectif. q. s. Aquae 8 parts 

Sapo. virid. ad. . . 100 " 

Erythrasma, described as a distinct disease by some authorities, is probably a 
form of chromophytosis affecting the upper and inner surfaces of the thighs, and 
often complicated with eczema intertrigo. Its dark red color and location are char- 
acteristic. 

The animal parasites of the skin belong to various classes, and may be divided 
in a general way into the Dermatozoa, living in the skin, and including the itch-insect 



11(5 



ILLUSTRATED SKIN DISEASES. 



and some less common parasites, and the Epizoa, living on the surface of the integu- 
ment or in the hair or the clothes, such as lice, fleas, bedbugs, etc. They are all 
transferable, though all persons are not equally liable to their invasion; they are 




Fig. 56. — Erythrasma. 
From photograph by the author. 



all more or less itchy, causing scratching, which leads to excoriations, blood-crusts, 
papules, vesicles, pustules, and pigmentation of the skin. Most of them belong to 
the class of the Acarina. The important ones are the itch-insect and lice, and only 
the maladies that thev occasion will be considered. 



SCABIES. 

Synonyms. — The itch, Kratze (Ger.), Gale (Fr.). 

Definition. — A contagious animal parasitic disease, due to the presence in the 
skin of the Acarus scabici, and characterized by itching and by varying evidences 
of the secondary general dermatitis, papules, vesicles, pustules, crusts, excoriations, 
and pigmentations. 

Symptoms and Course. — The itch is a very common disease in certain regions ; in 
England, according to Crocker, it forms 8 per cent, of all cases, while M'Call Ander- 
son found it in one quarter of all cases seen in dispensary practice in Scotland. It 
is common also in many other parts of Europe and in Asia; but in the United States 
Bulkley places the percentage of its occurrence as low as 2. Increasing emigration 
has made it more common, especially in the seaport towns. 

The itch-insect itself causes but few symptoms, especially at first, when present 
only in small numbers ; but it multiplies rapidly, and the new broods, burrowing 



INFLAMMATIONS. 



117 



into the skin, soon cause an irritation and itching that are generally quite severe, 
though they vary in intensity in different persons. They are worst at night, when the 
patient is warm in bed, and the parasite is most active. The acarus itself lives in 
the deeper succulent layers of the rete, from which it derives its nourishment; and 
to attain this position it digs a long, nar- 
row cuniculus or burrow, which passes 
obliquely downward through the upper 
epidermic layers, and is then extended 
onward through the rete parallel to the 
surface of the skin. It appears as a 
whitish or yellowish streak, from ^ to 
I inch in length, and is further marked 
by a succession of minute black spots, the 
little heaps of excrement and ova that the 
female acarus leaves behind in its onward 
progress. A few papules, vesicles, or pus- 
tules may be present at the site of the 
burrows, but there are no other signs of 
the presence of the parasite. 

Soon, however, another set of symp- 
toms, of much greater extent and severity, 
make their appearance, due to the increas- 
ing irritation caused by the multiplying 
parasite and the action of the patient's 
finger-nails. They are those of a more 
or less general eczema and dermatitis, and 
are so various in form that the eruption of 

scabies is essentially a polymorphic one. Papules, vesicles, pustules, excoriation?, 
blood- and pus-crusts, wheals, and hemorrhages are present in varying quantity ; 
they are most marked at the places favored by the parasite, but may be present over 
the whole surface of the body. In neglected cases these secondary inflammatory 
lesions may entirely mask the original disease, as in the so-called Norway itch. The 
itching is enormously increased, and may interfere with sleep to such an extent as 
to impair the patient's health. Finally, in very old cases, the repeated hemorrhages 
into the cutis, caused by the action of the finger-nails, may lead to a permanent 
diffuse pigmentation of the skin similar to that seen in prurigo and phtheiriasis. 

The portions of the body selected by the parasite for its habitat are characteristic. 
These are the soft skin of the interdigital clefts of the hands and feet, of the anterior 
surface of the wrists, of the penis and mammae, together with the areas subjected to 
steady pressure, as by garters, corsets, etc. The face and head are not involved. 
Untreated, the malady lasts indefinitely. 




Fig. 57. — Scabies. 

From photograph by the author. 



118 



ILLUSTRATED SKIN DISEASES. 



Etiology. — Infection with the itch-insect occurs almost always from other persons 
affected with the disease, but varieties of the same parasite are found on animals 
also, and occasionally the malady is acquired from horses, dogs, and other animals. 
The transfer from one human subject to another always occurs at night, when the 
skin is warm and the parasite most active ; there is no danger in the mere handling 
of affected individuals. Since the adult animals are rarely seen upon the surface, it 
is probably the larvae that are most frequently transferred. 

Pathology. — The Acarus scabiei belongs to the Acarina, and is an oval, crab-like 
organism with a straight intestinal canal, but no demonstrable vascular or respira- 
tory apparatus. The female is yellowish white in color, \ of a line in length, and 
just visible to the naked eye. Its margin is serrated; its convex back is studded 
with spines, and shows the transverse striae that mark the divisions of its chitinous 

envelop. The head is armed 
with four strong claw-like 
mandibles and two palpas. 
It has two anterior pairs of 
five-jointed legs armed with 
suckers and two similar pos- 
terior pairs provided with 
bristles. The oviducts and 
vagina open into the genito- 
urinary fold at the posterior 
end of the abdomen. The 
male acarus is one third 
smaller than the female, of 
similar structure, but has 
suckers on all its legs. The 
forked penis is placed in a 
horseshoe-shaped depres- 
sion in the abdomen. It 
lives upon the surface of the 
skin or under the crusts and 
scales, and dies soon after 
impregnation of the female 
has occurred. 

The female after fecunda- 
tion cuts through the horny 
epidermic cells with its sharp mandibles, and, elevating itself on its hind legs, bur- 
rows obliquely down into the skin toward the rete, and tunnels on along its upper 
surface. Thus the cuniculus is formed, along the course of which the parasite leaves 
behind it alternate ova and heaps of feces, the latter of which form the minute black 





Male. 




Track of itch-insect. 
After Neumann. 



Female. 

Acarus scabiei. 
After Kiichenmeister and Ziirn. 



Fig. 58. 



INFLAMMATIONS. 119 

dots that mark the burrows. The ova are oval, ^ of an inch in length, and 
from twenty to twenty-six are deposited by each acarus before its death, at the rate 
of about one daily. The larvae develop in from three to six days, dig separate holes 
for themselves in the walls of the burrow, and in from two to three weeks appear 
on the surface as fully developed parasites. 

The inflammatory reaction caused by these processes varies greatly in accordance 
with individual susceptibilities. Papules, vesicles, and pustules are present over the 
burrows ; but when the skin is delicate and the itching more intense, all the poly- 
morphous phenomena of eczema may be present, and affect extensive areas or the 
whole body. In bad cases the crusts and scales are full of acari, with their ova and 
remains. 

Diagnosis. — The characteristic features of the disease are the burrows, the parasites, 
and their ova ; the other lesions are those of the complicating eczema or dermatitis. 
The acarus is situated in the white non-inflammatory papule at the deeper extremity 
of the burrow. It may be obtained by opening the track with a fine needle and 
examining the fluid and detritus under the microscope in io-per-cent. caustic potash 
solution ; or the entire track can be snipped off with a pair of curved scissors, and 
similarly treated. The acarus itself, or its ova or feces, will certainly be found. 
The location of the eczema on the hands, more especially on the interdigital folds, 
on the penis, and around the genitals, etc., and the marked polymorphism, are also 
characteristic. Jessner has called attention to the fact that a black streak is left 
over the burrow if ink be brushed over the suspected surface and then wiped away. 

The diagnosis from other itchy diseases requires to be carefully made. Phtheiriasis 
shows the characteristic excoriations and the nits, but no general dermatitis. Simple 
pruritis has no seat of election and shows no burrows. Prurigo begins in very early 
life, has the characteristic nodules, and is situated on the extensor surfaces. Eczema 
has not the typical location or the tracks. In urticaria the wheals and the reflex 
excitability of the skin should suffice to prevent error. 

Prognosis is always good, and most cases can be speedily cured. 

Treatment. — If the skin is much inflamed, a short preliminary treatment with one 
of the anti-eczematous applications is required; and of these Lassar's salicylic-acid 
paste (No. 2, p. 43) is the best. Then a vigorous use of green soap, either pure or 
in the form of the tincture (No. 5, p. 43), will prepare the skin for the parasiticide. 
Sulphur is the one most generally used, either as the simple ointment (Nos. 24, 25, 
p. 64) or in accordance with Wilkinson's formula (No. 38, p. 82). This must be 
rubbed in thoroughly over the entire affected surfaces of the body nightly for three 
or four days and allowed to remain until morning, when a hot water-and-soap 
bath should be taken. Naphthol is more agreeable for private practice, and is to be 
used in the same way. It may be employed as ointment or oil (No. 41, p. 100, No. 
48, p. 105), but is especially efficacious in combination with green soap (No. 37, 
p. 82). The balsams of Peru or Tolu, either pure or diluted with oil, and more espe- 



120 ILLUSTRATED SKIN DISEASES. 

cially in combination with styrax (No. 5 7, p. 1 20), are preferred by Anderson on account 
of the absence of disagreeable odor and irritant effects. In the St. Louis Hospital 
at Paris, where very large numbers of these cases are treated, Hardy's modification 
of Helmerich's ointment (No. 58, p. 120) is uniformly employed. None other of the 
legion of antiscabitic applications need be mentioned here, since the above will suf- 
fice in all cases. 

No. 57. Scabies Ointment. No. 58. Hardy's Helmerich's Ointment. 

R: Bals. Peruv. R: Potass, carb. 1 part 

Styrac. . . . . aa. p. e. Sulphur sublim. ... 2 parts 

Adipis .... \]/ 2 

PHTHEIRIASIS. 

Synonyms* — Pediculosis. 

Definition. — A contagious animal parasitic disease of the skin, characterized by 
the presence thereon of pediculi and their ova, together with a secondary eczema 
and dermatitis. 

Three varieties of the hemipterous family Pediculidce or lice are parasitic on the 
human body. They are wingless, non-metamorphosing insects that live on the blood 
and the secretions of the body, which they obtain by suction. They are the so- 
called head-lice, body-lice, and crab-lice ; and they differ sufficiently in appearance, 
habits, and effects to require separate description. 

PHTHEIRIASIS CAPITIS. 

Synonyms. — Pediculosis capitis. 

Definition. — Pediculosis of the head, characterized by the appearance on the scalp 
and the hair of the Pediculiis capitis and its ova, together with a secondary eczema 
and dermatitis. 

Symptoms and Course. — The first symptom of pediculosis of the head is the itch- 
ing caused by the motion of the parasite and the suction by which it obtains its 
nourishment. This leads to scratching, excoriations, and eczematous and follicular 
inflammations, until finally more or less extensive areas of the scalp are raw and 
weeping, or covered with impetiginous crusts that mat the hair together. Washing 
the scalp and combing the hair become so painful that they are omitted, and the para- 
site flourishes in the foul-smelling, decomposing mass. The eczema may spread on to 
the face and neck, and the neighboring lymphatic glands become swollen and tender. 
The so-called plica polonica, where the hair remains for years matted together and 
swarming with vermin, is simply an exaggerated condition of phtheiriasis capitis. 
The malady is commonest among children on account of the greater chances of con- 
tagion in schools, and among the poorer classes on account of their uncleanliness ; 
but it occurs also in adults and among the well-to-do. 



INFLAMMATIONS. 121 

Etiology. — The parasite is always directly transferred. Sleeping together and 
the interchange of hats are the commonest methods of contagion. 

Pathology. — The Pediculus capitis is a small oval insect, 2-3 mm. long, with 
a segmented abdomen containing the genital organs, a broad thorax, from which 
project six hairy legs ending in strong hooked claws, and a triangular head provided 
with a pair of antennae, a suction-tube, and two prominent black eyes. The female 
is somewhat larger than the male, and lays from fifty to sixty eggs, which take from 
five to six days to hatch ; and in twenty days more the young are sexually mature. 
The rate of increase of the parasite is therefore extremely rapid, and it has been 
calculated that a single female will have five thousand descendants in eight weeks. 
The males are less numerous than the females, and are provided with a wedge-shaped 
penis on the upper surface of the last abdominal segment. The color of the pediculi 
varies with that of the skin, being white in the Eskimo, gray in the European, 
yellowish brown in the Chinese and Japanese, and black in the negro. 

The ovum is deposited in a bag known as the " nit," which is a pear-shaped 
chitinous envelop surrounding the hair and fastened to it by a sort of ferrule. Its 
broader end is directed toward the scalp, and is closed by a 
round operculum or lid, through which the embryo escapes. 
The empty nit remains ; and since the pediculus always affixes 
it to the portion of the hair close to the scalp, successive bags 
are attached as the hair grows, and their number on a single 
shaft, which may reach fifteen or twenty, will enable an estimate 
to be made of the length of time that the disease has existed. 
The secondary eczemas and dermatites, caused by the irritation 
of the parasite and infection by the finger-nails, do not differ FlG - S9-— Pediculus 

capitis. 

from the ordinary forms of these affections. The adenopathy photomicrograph by the author, 
is caused by absorption. 

Diagnosis. — The presence of the pediculi and their nits will distinguish phtheiriasis 
from eczema capitis, the only disease with which it is liable to be confounded. Ec- 
zema of the nape of the neck and the back of the head is almost always due to 
pediculosis, even in cases where the parasite is no longer present. 

Prognosis is of course good if the cause is recognized and the patient appropri- 
ately treated. 

No. 59. Kerosene Lotion. 

1J Petrolii . . . .60 parts 

01. olivae . . . . 30 " 
Bals. Peruv. . . . . 10 " 

Treatment. — Cutting the hair is not necessary, though it facilitates treatment and 
removes large numbers of nits. The carbolic or sublimate spirit (No. 34, p. 78, No. 
49, p. 108) can then be used daily, together with plenty of hot water and soap and 




122 



ILLUSTRATED SKIN DISEASES. 



the fine-tooth comb. In dispensary practice kerosene, either alone or with olive-oil 
and balsam of Peru (No. 59, p. 121), is the readiest and best application. It should 
be rubbed thoroughly into the hair in the evening (care being taken to avoid acci- 
dental ignition), the head closely bound up until morning, and then thoroughly 
washed. This, repeated three or four nights in succession, will destroy the parasites 
and embryos ; but the nits are more resistant, and require the free use of alcohol or 

vinegar and the comb for 
their removal. The eczema 
and dermatitis sometimes re- 
quire treatment, though the 
removal of their cause will 
generally suffice. The oint- 
ment of ammoniated mercury 
fulfils this indication, and is a 
parasiticide also ; it is there- 
fore to be preferred in private 
practice. The same may be 
said of the 5-per-cent. naph- 
tholated oil (No. 41, p. 100). 

PHTHEIRIASIS VESTI- 
MENTI. 

Synonyms. — Pediculosis 
vestimenti s. corporis. 

Definition. — Pediculosis 
of the bod}-, characterized by 
the presence of the Pcdiculus 
corporis and its ova in the 
clothing, by the lesions caused 
by it upon the skin, and by a 
secondary eczema and der- 
matitis. 

Symptoms and Course. — 
When the pediculus with- 
draws its haustellum from a 
glandularorificeasmall hem- 
orrhage occurs in the follicle, 
with an area of cedema around it, appearing as a minute red dot surrounded by a 
wheal. Itching and burning are felt, which the patient relieves by scratching. When 
the top of the cedematous papules is torn off, and bleeding relieves the congested 
vessels, the itching ceases. The original lesions are transitory and unimportant; 




FlG. 60. — Phtheiriasis vestimenti. 
After Van Haren-Nomaii. 




INFLAMMATIONS. 123 

but the scratch lesions are much more permanent, appearing as characteristic linear, 
parallel, hemorrhagic streaks or rows of torn papules. They are located more espe- 
cially on the neck and waist, where the folds of the clothing fit tightest, and where 
the parasite finds a home in the seams. In bad cases infection from the finger-nails 
gives rise to furuncles, abscesses, and deeper ulcerations, ending in superficial scars. 
When the malady has been present for many years, as is frequently the case with 
tramps and lodging-house dwellers, the multitudinous hemorrhages occasion a gen- 
eral diffuse pigmentation of the skin which is characteristic. 

Etiology. — Body-lice are transferred from one person to another by contact with 
infected bed-linen, clothing, furniture, etc. While most frequently seen in persons 
of dirty habits, any one may acquire them in street-cars and 
other public places. 

Pathology. — The Pediculus corporis is a grayish-yellow 
oval insect, similar in form and structure to the head-louse, 
but somewhat larger, measuring 2—3 mm. Its habitat is the 
seams and folds of the clothing next to the skin, and it seeks 
the integument only for the purpose of feeding. It obtains 
its nourishment by suction after thrusting its haustellum into 
a follicle-mouth. Its color when swollen with blood is red. 
The nits are small, yellowish, rounded bodies, and are laid in 
the seams or in the meshes of coarse underwear. The num- Fig. bi.—Pedkuhis vesti- 
ber of the embryos and the time required for their hatching After KucheTIeistir and Ziim. 
and maturity are about the same as with the Pedicttlus capitis. 

Diagnosis. — The location of the secondary lesions on the neck, waist, buttocks, 
thighs, etc., the parallel scratch- marks, the minute hemorrhagic papules, the pigmen- 
tation, and the finding of the parasite and its nits in the clothing will distinguish 
phtheiriasis corporis from the other itchy diseases. General pruritus is rare, and the 
partial form is usually localized around the orifices of the body. Urticaria has its 
wheals, which appear anywhere, and an irritable skin, and is associated with diges- 
tive disturbances. Scabies has the characteristic tracks and the equally characteristic 
location around the genitals and in the interdigital folds. Prurigo begins in youth 
and affects the extensor surfaces chiefly. Eczema is more frankly inflammatory, 
with weeping surfaces and crusts at its favorite seats. 

Prognosis. — This is good if the nits and embryos can be destroyed. This is not 
always possible, and some of these patients go on for years affected with the disease, 
sharing the supposition, so common in the lower classes, that the skin breeds the 
vermin. 

Treatment. — Disinfection of the clothes is the only treatment. Underwear can 
be boiled, but the outer clothing must be exposed to a dry heat of at least 160 to 
I 7S°, by wrapping it up in paper and placing it in a carefully heated oven. 
The skin need not be treated, though the staphisagria ointment recommended by 



124 



ILLUSTRATED SKIN DISEASES. 



Duhring (No. 60, p. 124) will destroy any parasites or embryos that may be on it. 
The excoriations may require a bland ointment or dusting powder (No. 18, p. 61, 
No. 26, p. 70, No. 54, p. 113). 

No. 60. Duhring 1 s Staphisagria Ointment. 



$ Pulv. staphisagrise 
Ungt. simplicis . 



1 part 
4 parts 



PHTHEIRIASIS PUBIS. 

Synonyms. — Phtheiriasis inguinalis, pediculosis pubis, crabs. 

Definition. — Pediculosis of the genital regions, and sometimes of all the other 

hairy surfaces except the scalp, characterized by the presence of the Pediculus pubis 

and its ova, together with a secondary eczema and dermatitis. 

Symptoms and Course. — The crab-louse is found most commonly in the pubic 

region, but sometimes seen in the axillae, in the beard, mustache, eyebrows, and lashes. 

In very hairy individuals the entire body, save the head, hands, and feet, may be 

affected. The symptoms caused by its presence consist of the itching, together 

with the secondary excoriations and eczemas, as is the 

case with the other pediculi. The parasites are small 

and transparent, and therefore sometimes hard to de- 
tect ; but they can be seen lying along the hairs, which 

they clutch with their strong claws, while their heads 

remain buried in the follicle-mouths. Minute heaps 

of reddish excrement are visible on the skin among the 

hair-shafts. Considerable traction with the forceps is 

required to detach them. The nits are smaller than 

those of the other varieties, but 
of similar structure, and at- 
tached to the hairs in the same 
way. 

Etiology. — Contagion al- 
most always occurs during 
sexual intercourse. It may, 
however, happen without it, as 
was shown to my satisfaction 
quite recently, when almost all 

the tenants and employees on one floor of a very large office building in New York 

became infected, and the parasites were found on the woodwork of the public 

water-closets. 

Pathology. — The pubic is the smallest of the three varieties of pediculi, and is 





Fig. 62. — Pediculus pubis. 
Photomicrograph by the author. 



Fig. 63. — Nit and embryo — Pedicu- 
lus pubis. 
Photomicrograph by the author. 




COPYRIGHT BY E. B. TREAT 4 CO. , N. Y. 



PHOTOGRAVURE 4 COLOR CO., N. Y. 



ECZEMA IMPETIGINOSUM 



PLATE XV 



I . 
Diagno; 

TfCAtl!': 



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- 










































ECZEMA IMPETIGINOSUM 






INFLAMMATIONS. 125 

a crab-like insect 1-2 mm. in length. Its flat body is short and round, and the 
thorax and abdomen are merged into one. Its color is a transparent grayish yellow. 
It obtains its nourishment by means of an haustellum, as do the other lice. 

Diagnosis. — The itching in the genital region is sufficiently characteristic, and a 
close inspection in a good light will always reveal the presence of the parasite. In 
the better class of patients a sort of " pediculiphobia " is sometimes left behind, and 
they will often complain of itching, and claim to be still infected, long after all the 
vermin have been destroyed. 

Treatment. — Almost any of the parasiticides previously recommended will be 
found efficacious. The sublimate spirit (No. 49, p. 108) does very well, but it is liable 
to irritate the skin of the scrotum and the thighs, and cannot be used over the whole 
body for fear of absorption. Mercurial ointment, the common remedy for the con- 
dition, has similar limitations. In extensive cases the naphtholated oil (No. 41, 
p. 100) or the carbolic lotion (No. 11, p. 56) or the ointment of ammoniated mercury 
may be used ; they are slower, but safe and effective. Rosenbach recommends a 
mixture of balsam of Peru and ether (No. 61, p. 125). 

No. 61. .Rosenbach' s Lotion for Pediculosis. 

fy Bals. Peruv. . . . -3° parts 
Ether, sulph. . . . 100 " 

ECZEMA. 

Synonyms. — Salt rheum, tetter, Salzfluss (Ger.). 

Definition. — A catarrhal inflammation of the skin, characterized by the appear- 
ance of erythematous areas, papules, vesicles, pustules, or weeping or scaling surfaces, 
and accompanied by itching. 

Symptoms and Course. — Eczema is the commonest of all the diseases of the skin, 
forming about one fourth of all cases. It is essentially a simple catarrhal inflam- 
mation, and its symptoms in general are the classical ones of heat, redness, pain, 
and swelling. They are modified, however, by the fact that the skin is exposed to 
the action of the external influences, and is not confined in the midst of other organs 
and tissues. These factors diminish the heat and redness ; cause pain to be replaced 
most often by itching, though occasionally by burning ; permit the exudation and 
emigration incidental to the inflammatory process to flow off from the surface of the 
affected tissue ; and render the affected organ liable to external injuries and microbic 
infection. As with other inflammations, the process terminates either in resolution, 
with absorption or extrusion of the effused products, or in organization, or, finally, 
in pus formation. The disease may be a transitory one, lasting only for a few days ; 
or it may endure, with exacerbations and remissions, for a lifetime. Save in very 
extensive and unusual cases there is no accompanying constitutional disturbance. 



1:26 



ILLUSTRATED SKIN DISEASES. 




The symptomatology of eczema is essentially protean ; it may appear as an 
erythematous patch, as a moist and oozing surface, as a collection of vesicles, pap- 
ules, or pustules, or as a crusted and desquamating area. These differences depend 
upon the cause of the affection, the stage that it is in, and the conditions and sur- 
roundings of the affected skin. Several varieties of lesion are often present together, 
and,. in accordance with the predominant one, various kinds or, more properly, vari- 
ous stages of ecze- 
ma are recognized. 
The course, loca- 
tion, and etiology of 
the disease give rise 
to still other vari- 
eties that require 
consideration. 

i. Eczema ery- 
thematosum. The 
process commences 
with the appearance 
of one or a number 
of slightly elevated, 
pinkish, itchy mac- 
ules, of indefinite 
outline, which soon 
spread and coalesce 
into larger reddened 
areas. The entire 
surface is swollen ; 
its color varies from 
a light pink to a 
dusky red ; there is 
moderate heat and 
a varying amount of 
itching. It is seen 
most commonly 
upon the face, where 

it appears as a general diffuse redness, with accentuation of the natural folds and 
wrinkles of the skin; but it may affect the palms, the soles, and the regions around 
the genitals. The process may last only a short time, but it is frequently very chronic, 
especially in the old. Mental excitement, external heat, a heavy meal, or the use 
of alcohol aggravates it temporarily. It usually terminates in resolution ; the red- 
ness and swelling fade, the itching ceases, and the process ends with a fine epithelial 




Fig. 64. — Eczema papillosum. 
From photograph by the author. 




TYPOGRAVURE. 



COPYRIGHT, 1905, BY E. S. TREAT 4 CO., N. Y. 

ECZEMA SEBORRHOICUM. 



PLATE LVIII. 



INFLAMMATIONS. 



127 



desquamation; but it may develop into one of the other forms of eczema. When it 
has been long present, a permanent thickening of the skin, due to an inflammatory- 
new growth of connective tissue, is left behind. 

2. Eczema papulosum. This is a common and very obstinate form of eczema, 
and is usually seen on the trunk and the extensor surfaces of the limbs, but rarely 
affecting the head or face. The eruption consists of millet-sized, acuminate, inflam- 
matory papules, isolated or grouped, and often spread over a considerable area of 
the body. Their color is reddish or violaceous. They may remain papules during 
the entire course of the disease, they may become confluent in places and form 
larger, irregular patches, or they may go on to form vesicles and weeping surfaces. 
The itching is intense, and excoriations and blood-crusts are common. 

3. Eczema vesiculosum. This begins with a diffuse or punctate redness, accom- 
panied by itching and burning, and papules soon appear that rapidly become vesicles. 
They are pin-point sized, acuminate, irregularly arranged, filled with a clear serum, 




Fig. 65. — Eczema vesiculosum. 

After Van Haren-Noman. 



and surrounded by a narrow inflammatory areola. Occasionally they are grouped, 
and sometimes they become confluent and form irregular masses. The vesicles grow 
slowly until they finally rupture, either spontaneously or in consequence of the 
scratching. A red, weeping surface is left behind, the secretion of which dries up 
into thin, yellow, honey-like crusts, or flows off in drops. As the inflammation sub- 
sides the serous discharge lessens, the redness fades, the crusts fall off, and, with slight 
desquamation, a new epithelial covering is formed. Eczema vesiculosum occurs with 
especial frequency on the faces of children. It may last for some time unchanged, but 
more commonly it runs into the form known as eczema rubrum or eczema madidans. 



128 



ILLUSTRATED SKIN DISEASES. 



4. Eczema pustulosum or eczema impetiginosum is the variety in which the 
lesions either originate as pustules or rapidly become such after a vesicular stage. 
A secondary infection with pus-cocci probably occurs. At first minute, the pustules 
rapidly become larger and then rupture, and their contents dry up into dark, black- 
ish or greenish or yel- 
lowish crusts. It occurs 
most frequently on the 
scalp and face of chil- 
dren and in debilitated 
patients. After persist- 
ing foranindefinitetime, 
it gradually disappears 
in the same way as does 
the vesicular form. 

While each one of 
these four chief types of 
eczema may occuralone 
and persist unchanged, 
it is more common to 
find them intermingled. 
They are, in fact, rather 
to be considered as dif- 
ferent stages of the same 
process ; and an eczema 
may, and often does, 
pass through all of them 
before the inflammation 
subsides. A number 
of other terms are em- 
ployed to describe va- 
rieties of this protean 
malady, and of these 
the following forms are 
characteristic and im- 
portant enough to merit 
especial mention. 

5. Eczema acutum. This may be of the erythematous, vesicular, papular, or 
pustular form, and usually passes through all four stages. The reddened and swollen 
skin soon becomes covered with papules, vesicles, and pustules ; these latter rupture, 
leaving a red and oozing surface behind. After a few davs or weeks the secretion 
diminishes, the redness disappears, and the process ends with desquamation. It may 
also terminate in chronic eczema. The itching and burning are intense, and there 




FlG. 66. — Eczema squamosum. 
From photograph by the author. 




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INFLAMMATIONS. 



129 



may be much oedema in locations, as on the eyelids, where the subcutaneous connec- 
tive tissue is loose. The extensive general forms of acute eczema are rare, and may be 
accompanied by a febrile movement. It is very liable to relapse at irregular intervals. 

6. Eczema chronicum. This may appear as any one of the chief varieties, but is 
usually squamous in form, and follows an acute attack. The long-standing chronic 
inflammation leads to hypertrophic thickening, Assuring, and pigmentation of the 
affected parts. It is usually due to some permanent cause, most frequently the 
patient's occupation. It often persists for years. 

7. Eczema squamosum represents the final stage of any of the other forms of the 
disease ; but extremely chronic cases may be squamous almost from the beginning. 
The amount of exudation is small ; the skin is reddened in patches or more diffusely, 
and is covered with fine, grayish-white scales. 

8. Eczema crustosum is simply one of the other forms in which the serum has 
dried up into crusts, whose color depends on the nature of the secretion and the 
varying amounts of serum, pus, sebum, blood, and dirt that are intermingled. 
Under these crusts we find a diffusely reddened, weeping surface. 

9. Eczema verrucosum occurs more especially on the lower extremities in the aged, 
when the long-continued chronic inflammation leads to hypertrophy and thickening of 
the skin. The entire surface is dry and warty and covered with thin crusts and scales. 

10. Eczema rubrum or eczema madidans is 
usually a consequence or continuance of eczema 
vesiculosum. The affected surface is red and 
moist ; and a thick, gummy serum exudes from it, 
which may either flow away or dry up into yel- 
lowish- or greenish-brown crusts. It is oftenest 
seen on the lower extremities of elderly people, 
and may be very extensive, involving the whole 
limb. It is very chronic, often lasting for years. 

1 1. Eczema intertrigo. This is seen where the 
surfaces of the skin are in apposition, and where 
maceration of the parts with sweat and serum oc- 
curs. It appears as a diffuse, red, weeping surface, 
and is commonest at the flexures of the joints, on 
the nates and genitals (especially in children), and 
around the neck. 

12. Eczema capitis. This may occur in iso- 
lated patches, or be generally diffused over the head. The sticky serum mats the 
hair together, and pediculi, which are the cause of the inflammation, are almost always 
present. In the more chronic forms the whole scalp is scaly, forming what is known 
as pityriasis of the head. 

13. Eczema faciei. This is usually primary and acute, and is very common in 
infants, forming the crusta lactea. It is generally at first vesicular and then diffuse, 




Fig. 67. — Eczema faciei. 
From photograph by the author. 



130 



ILLUSTRATED SKIN DISEASES. 



and is accompanied by much oozing. The more chronic forms in adults are often 
erythematous; the skin is red and swollen, the natural wrinkles are exaggerated, the 
lids are swollen, and the itching and burning are intense. 

14. Eczema barbae is one of the varieties of the so-called barber's itch. The 
bearded skin is red, swollen, and tender, and the hairs are matted together with 
gummy secretion. Secondary coccigenic infection, leading to the formation of 
pustules around the hair-follicles, is common. 





Fig. 68. — Eczema of the hands. 
From photograph by the author. 



15. Eczema manuum. This is a very common affection, and while it may be 
acutely vesicular or pustular, it usually assumes the chronic indurated form. When 
the palms are affected the skin is thickened and fissured at the flexures and folds. 
It is commonly due to the patient's occupation, and is found in masons, gilders, pol- 
ishers, etc., being caused by the irritating materials that they use. 

16. Eczema genitalium is usually of the chronic erythematous or squamous form, 
and most commonly affects the scrotum. The itching is frequently intense, and the 
malady is very rebellious to treatment. 




- Z '.J 2 -- . = 1 



COPYRIGHT, 1902, BY F. B. TREAT 4 CO., N. Y. 



ECZEMA SEBORRHEICUM. 



FLATE LI. 



V 





















, 






- 










v 
















INFLAMMATIONS. 



131 



1 7. Eczema unguium. This occasionally occurs in connection with other eczem- 
atous eruptions. The nails become brittle and break, are furrowed with dark lines, 
and finally fall off. 

1 8. Eczema seborrheicum. This is a form that Unna first called attention to, and 
which certainly differs very markedly from all the ordinary types of eczema. It ap- 
pears as rounded or circinate yellowish-red patches, spreading peripherically, with 
a papular or scaly margin and a fading center. Its favorite location is the sternum 
and the center of the back, the scalp, eyebrows, and mustache, the axillae, and the 
genitocrural fold. On .the scalp it appears as a diffuse or general redness, with 
minute oily scales, and a very distinct reddish border along the forehead and temples, 
the corona seborrheicum. It is really a combination of seborrhea in either its dry 
or oily form with an eczematous inflammation. It is undoubtedly of parasitic origin, 
and belongs in the section with ringworm and similar affections rather than in that 
of the simple inflammations. 

Etiology. — Eczema occurs at 
all ages and in all conditions of life. 
Its frequency during infancy is to 
be ascribed to the delicacy of the 
skin at that age and its prompt re- 
action to irritants of external and 
internal origin. The causes of ec- 
zema are very numerous, and are 
either internal and general, or ex- 
ternal and local. 

The internal causes of eczema 
are, of course, more or less indefi- 
nite and incapable of exact proof. 
Nevertheless the malady does oc- 
cur with especial frequency in con- 
nection with nervous diseases, in 
anemia, chlorosis and leucocy- 
themia, in rickety individuals, in 
gravid women, in those affected 
with asthma, and together with 
digestive disturbances and obsti- 
nate constipation. 

The local causes of eczema are 
too many to be enumerated in de- 
tail. They consist of : [a) Parasites. 
While the claim advanced by Unna to have found a bacterial cause for the various 
eczemas is by no means substantiated, some of these maladies are undoubtedly of 




Fig. 69. — Eczema acutuni. 
From photograph by the author. 



132 ILLUSTRATED SKIN DISEASES. 

that nature. This is notably the case with eczema seborrheicum. I believe that 
only the eczemas that have a marked seborrheal element, or that appear with sharply 
circumscribed circular or gyrate outlines, can in the present state of our knowledge 
be positively claimed as parasitic. The animal parasites, pediculi and the itch-insect, 
cause a secondary eczema of the skin, and the same is true of the trichophyton. 
(b) Mechanical, chemical, and thermic irritants. Many substances, such as mercury, 
iodoform, creolin, carbolic acid, petroleum, turpentine, sulphur, and the aniline dyes 
cause an eczematous inflammation of the parts exposed to their influence ; so also do 
the poisons of the Rhus toxicodendron and Rhus venenata. The ultra-violet chem- 
ical rays of sunlight cause eczema solare, and the electric-light rays have a similar 
effect. Strong acids and alkalis are efficient causes ; so also are many soaps ; and 
even water, when used to excess, can set up an eczematous inflammation. Finally, 
the finger-nails are responsible for many eczemas, more especially in the itchy erup- 
tions, pruritus, prurigo, scabies, etc. 

Pathology. — Eczema is a simple catarrhal inflammation of the skin, and does 
not differ essentially from similar inflammations of the mucosae. The ordinary vas- 
cular phenomena of inflammation and their consequences are present ; but the process 
varies somewhat in accordance with the intensity and the duration of the inflamma- 
tion. The fluid that is poured out is the blood-serum, a yellow, clear, sticky, syrupy 
material, drying up into yellowish crusts. In the erythematous form the exudation 
is moderate and there is increased activity of the epidermic cells, as is shown by the 
desquamation. In the papular form the papillary vessels are chiefly affected, and 
the exudation and emigration are great enough to elevate the corneous layer. The 
vesicular form is simply an exaggeration of the papular; the exudation is sufficient 
to accumulate as a fluid mass in the corium. In the pustular form there is in- 
creased cell-emigration and multiplication of the connective-tissue corpuscles. The 
changes of chronic eczema are more deeply seated in the corium and subcutis. The 
parts are thickened by the infiltration and new connective-tissue formation, and 
pigment is deposited in the deeper layers of the rete and corium. The verrucous 
form is marked chiefly by the permanent enlargement of the papillae. In the 
squamous form the epithelial-cell proliferation is increased. 

Diagnosis. — Eczema is the most frequent and important disease of the skin, and 
its diagnosis is often difficult on account of the polymorphous nature of its manifes- 
tations, and from the fact that in various other maladies the secondary lesions are 
eczematous in character and may mask the original disease. Where one of the chief 
typical forms is present the diagnosis will present no difficulties ; but the mixed forms 
may resemble a number of other affections. In a general way the diagnosis is made 
from the inflammatory symptoms and the formation of acuminate papules and vesi- 
cles, exudation, crusting and scaling and thickening, together with the absence of 
sharp limitation of the eruption, the polymorphism, and the intense itching. The 
principal maladies which require differentiation from it are : 




ECZEMA PALM/E. 




TYPOGRAVURE. 



COPYRIGHT BY E. B. TREAT * CO., N. Y. 



SYPHILODERMA Palm*. 



PLATE XVI. 






- 








(0) Psi 








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. 






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fold. 










-ular 








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SYPH mm*. 



PLATE X> 



INFLAMMATIONS. 133 

(a) Erysipelas, which has marked and acute general febrile symptoms, with a vivid, 
smooth, shining redness, swelling, sharp borders, and is never weeping or papular or 
vesicular, (d) Psoriasis, which has shining silvery scales on a punctate bleeding 
base, is sharply circumscribed, never shows vesiculation or oozing, and is situated 
most often on the extensor surfaces of the limbs, (c) Herpes facialis, which may- 
be distinguished by the presence of a sharply limited group of vesicles of the same 
age situated on an inflamed base, (d) Eczema marginatum has a sharply limited 
brownish-red margin of curved outline, and is situated in the axilla and the genito- 
crural fold, (e) Lupus erythematosus. This sometimes resembles an eczema very 
closely, but differs from it in its very slow progress, the absence of vesiculation and 
itching, and the presence of scanty seborrheal scales with plugs from the glandular 
orifices projecting from their under surfaces, and is followed by superficial central 
scarring. (/") Pemphigus, which has large blebs separated from one another by 
sound skin, (g) Phtheiriasis vestimenti. This often causes lesions that are essen- 
tially those of a papular eczema; but the discovery of the cause in the clothing will 
serve to prevent error. (A) Scabies. Here also the lesions are eczematous ; but the 
tracks, the history of contagion, the seat at the clefts of the fingers and on the geni- 
tals, should suffice to prevent mistake. (/) Syphilis. The papules of syphilis are hard, 
copper-colored, do not disappear on pressure, and are unaccompanied by itching. The 
ulcers of syphilis have hard, infiltrated edges and dirty necrotic bases, while ulceration 
does not occur in eczema. The diagnosis between syphilis and eczema of the palms is 
often a matter of difficulty ; but the sharply limited dark-brown infiltration, with semi- 
detached scales at the margins, the central clearing, and the presence of other mani- 
festations of the disease are characteristic, (j) Impetigo contagiosa has isolated yellow 
circular crusts on reddened bases, and usually a history of contagion, (k) Lichen 
planus. Here the papules are flat-topped, angular, often umbilicated, and violaceous 
in color ; they are grouped and symmetrical, and affect the backs of the hands and 
the forearms by preference. (/) Seborrhea is never moist, and shows the charac- 
teristic fatty scales, (m) Trichophytosis may resemble a papulo-erythematous 
eczema very closely ; but the patches are distinctly circular or gyrate, their mar- 
gins are abrupt, and the microscope will always settle the diagnosis. (;z) Dermatitis, 
as from external irritants, while it may resemble an eczema very closely, has a 
history and course that are characteristic, and rapidly subsides when its cause is 
removed. 

Prognosis. — This in a general way is good, though there are exceptions. Acute 
eczema is always curable, but is very liable to relapse. Chronic eczema may be 
incurable when its underlying cause cannot be removed. In those rare cases in 
which the entire integument is involved the affection is a grave one ; the important 
functions of the skin are interfered with, and the excessive discharge causes ex- 
haustion, which is increased by the loss of rest due to the itching. The chronic 
eczemas of the aged may be incurable, though they can always be relieved. Ec- 



I 



134 



ILLUSTRATED SKIN DISEASES. 



zema leaves no permanent mark on the skin; it never causes ulceration or the 
formation of cicatricial tissue, and the thickening and pigmentation that some- 
times result from it disappear in the course of time. 

Treatment. — A methodic and careful treat- 
ment, which takes into account the underlying 
and accompanying general conditions as well 
as the nature and stage of the local malady, 
will give the best results. The topical treat- 
ment is undoubtedly the most important, but 
the other means must not be neglected. 




No. 62. Diuretic Mixture. 



$ Kali acetat. . 
Spts. aether, nit. 
Syrp. aurant. 
Aq. fcenic. . 



i part 
2 parts 
4 " 

12 " 



Fig. 70. — Eczema crustosum. 
From photograph by the author. 



General Treatment. — This consists in 
the appropriate management of any abnormal 
condition of the general system or of other or- 
gans which may influence the origin or per- 
sistence of the eczematous malady. Anemic 
and chlorotic patients require phosphorus, 
quinine, iron, strychnine, and the mineral 
acids, with carefully prescribed diet and ex- 
ercise. Startin's mixture (No. 19, p. 64) is 
very useful here. Where rheumatic or gouty 
symptoms are present the alkalis, more espe- 
cially the alkaline diuretics (No. 62, p. 134), 
either alone or with colchicum, are required. 
They are also useful where there is functional 
kidney derangement. When dyspepsia and 
constipation are present the diet must be care- 
fully regulated, more especially as regards 
meats ; and laxatives, such as cascara and the 
various mineral waters, must be regularly used. 
It is sometimes necessary to put the patient 
on a milk diet for a time. In fact, the care of 
the digestive tract is of the utmost importance 
in eczema; and, in the infantile forms more 
especially, little permanent good will be ac- 



INFLAMMATIONS. 



135 



complished unless the diet and the bowels be most carefully regulated. In the 
impetiginous eczemas, and in general in all the so-called strumous cases, where the 
tendency to chronic inflammation is marked, cod-liver oil in full doses, perhaps 
combined with the syrup of the iodide of iron, is most useful. 

Of the internal remedies directed to the eczema itself we need mention only two, 
arsenic and ichthyol. The former may be given as the Asiatic pill (No. 6, p. 46) or 
as Fowler's solution in doses of 3 to 1 5 drops three times daily, well diluted with 
water and administered after meals. It is useful only in the chronic squamous 
cases when the digestive tract is in good condition, and it must be pushed up to the 
point of toleration. Ichthyol may be given in pill form, preferably combined with 
arsenic (No. 63, p. 135). 

No. 63. Ichthyol-Arsenic Pills. 

Bt Amnion, sulph-ichthyolat. 3i ss 
Ac. arseniosi . . . gr. 2 
Pulv. glycyrrhizae . . q. s. ut f. pil. No. 90 
Sig. 2 to 3 t. d. after meals. 

LOCAL TREATMENT. — An indispensable preliminary step is to remove all irrita- 
tion from the inflamed surface. Perhaps the commonest source of this is water, and 
in the acuter cases its use must be restricted or even forbidden altogether. Warm 
olive-oil may be employed for cleansing. Other irritants are the atmosphere, soaps, 
decomposing secretions, the finger-nails, and mechanical or chemical influences. 
The crusts and scales must be removed after a thorough soaking with olive-oil, and 
for this purpose a single application of the tincture of green soap (No. 5, p. 43) and 
water is admissible. The further local treatment will depend on the nature and stage 
of the eczematous process. 



No. 64. Zinc- Camphor Powder. 



ft Pulv. camph. 
Pulv. zinci ox. 
Pulv. amyli . 



1 part 
3 parts 
12 " 



No. 65. Zinc-oil. 



ft Pulv. zinci ox. 
01. olivae 



30 parts 

25 " 



No. 66. Lime-oil. 
R 01. amygdal. 
Aq. calcis 



aa. p. e. 



No. 67. Alkaline Lotion. 



ft Sod. bicarb. 
Aquae . 



1 part 
50 parts 



No. 68. Cooling Salve. 

ft Adip. lanae ... 1 part 

Adip. suillis ... 2 parts 

Aq. rosse (s. calcis) . . 3 to 5 " 



No. 69. Rose-water Ointment. 



ft Aq. rosae 
Adip. lanae 
Adip. suillis 



3 parts 

3 " 
2 " 



136 ILLUSTRATED SKIN DISEASES. 

Acute eczema. Remedies of the mildest kind are here required, and lotions and 
powders are more generally applicable than salves and pastes. In the erythematous 
and acute vesicular forms the zinc-oxide powder (No. 18, p. 61), either alone or 
with camphor (No. 64, p. 135), may be employed; or the zinc- or lime-oils (Nos. 65, 
66, p. 135), followed by a dusting" powder. Weak alkaline lotions are often useful in 
the early stages (No. 67, p. 135). In the less acute degrees the various cooling salves, 
of which No. 68 (p. 135) is an example, may be used, as may also the boracic-acid 
ointment (No. 29, p. 74) or the rose-water ointment (No. 69, p. 135). The use of 
powders after these various applications must be persisted in as long as there is 
much secretion. The salves and plaster-mulls can often be employed with ad- 
vantage. 

For the relief of the itching, which is especially intense in the papular form of 
the disease, the 5-per-cent. menthol spirit (No. 33, p. 78) or the 3-per-cent. carbolic 
spirit (No. 34, p. 78) may be employed. As the inflammation subsides, painting the 
parts once daily with the tar tincture (No. 45, p. 104), followed by the salicylic-men- 
thol paste (No. 70, p. 136), will be found useful. 

No. 70. Salicylic- Menthol Paste. No. 71. Diachylon Ointment. 

R Ac. salicyl. ... 1 part fy Emplast. diachyli . . 3 parts 

Menthol . . . . 1 to 2 parts Aq. rosae 

Pulv. zinci ox. Adip. Iana3 

Pulv. amyli Adip. suillis . . . aa. 1 part 

Adip. lanse 

Petrolati . . . . aa. 10 " 

Chronic eczema. Acute exacerbations or acutely inflamed portions of a chronic 
eczema must be treated with powders and pastes, as above directed. For the more 
usual forms the diachylon ointment (No. 71, p. 136) or Lassar's paste (No. 2, p. 43) 
is appropriate. The mode of their employment is by no means unimportant. They 
should not be rubbed into the affected part or applied with the finger, but should be 
spread about as thick as the back of a table-knife on narrow pieces of linen or band- 
age, and fastened to the affected part in overlapping strips. The tar preparations 
are perhaps our most valuable remedies in the squamous stage, but they should 
never be used so long as there is much secretion. We may employ the tar spirit 
(No. 10, p. 56) or the ointment (No. 22, p. 64), gradually increasing the propor- 
tion of tar as the process requires it. In some cases we must use the ol. cadini or 
rusci pure, with the addition of 10 per cent, of ether. The tar plaster-mulls are 
elegant and efficacious applications. Ichthyol acts like tar and may be similarly 
employed (No. 72, p. 137). In chronic seborrheal eczema, so frequent upon the 
head, sternum, and back, the sulphur paste (No. 24, p. 64) or the sulphur and the 
resorcin ointments (Nos. 20, 25, p. 64) are of use. 





PSORIASIS OF THE NAILS. 



ONYCHOLYSIS. 





TYPOGRAVURE. 



COPYRIGHT, 1905, BY E. B. TREAT A CO., N. Y. 



ECZEMA UNGUIUM. 



LEUCONYCHINA STRIATA. 



PLATE LIX. 



■• 






In eczei 



' 



No. 72. 



t. . 

t. . 
lae 


















i 

. ad theii n 

; 



. . . 

I 
- 









I accural 

- 
i 



m the fii 









uum. 









' 



■ 







ONYCHOLYSIS. 








LEUCONYCHINA STRIATA. 



E LIX. 



Amnion, sulph-ichthyolat. 




$ Pulv. calamini 


Aq. dest. . 


aa. 5 parts 


Pulv. zinci ox. 


Adip. benzoat. . 


i5 " 


Glycerini 


Adip. lanae 


25 " 


Aq. rosas 



INFLAMMATIONS. 137 

In the chronic indurated eczemas the 10- to 40-per-cent. salicylic plaster is 
effective, as is also the free use of tar soap. Where the thickening is very marked, 
daily friction of green soap, followed by one of the above-mentioned salves, is indi- 
cated. In eczemas of parasitic origin 5- to 10-per-cent. chrysarobin and pyrogallol 
ointments are very serviceable. Whatever application we employ in chronic eczema 
we must be careful to avoid too much irritation, lest we make an acute inflamma- 
tion of a chronic one. This applies especially to tar and similar preparations. 

No. 72. Ichthyol Ointment. No. 73. Calamine Lotion. 

2 parts 
2 " 
1 part 
. 30 parts 

There remains to be mentioned the most appropriate treatment for some of the 
commoner varieties of the disease. In eczema capitis we must first remove the 
pediculi and their nits. This may be effected by soaking the head with kerosene 
at night, and washing it with soap and hot water in the morning, or by the use of 
the sublimate spirit (No. 49, p. 108). It is rarely necessary to cut the hair. The crusts 
must be softened and carefully removed by means of compresses soaked in olive- or 
cod-liver oil, followed by washings with ordinary or green soap. The lime-oil (No. 
66, p. 135) or the boracic-acid salve (No. 29, p. 74) can then be employed. 

Eczema faciei. The zinc salve or plaster-mulls cut into strips and accurately 
fitted to the face are very excellent. In the acute erythematous form the calamine 
lotion (No. 73, p. 137) will be found effective, as will also the cooling and rose-water 
salves (Nos. 68, 69, p. 135). The more chronic cases require the sulphur and 
tannin pastes (No. 20, p. 64, No. 50, p. 108). I have found a 2-per-cent. ichthyol 
salve very useful in the acute facial eczemas of children. Fissures of the lips may 
be touched with the nitrate-of-silver stick, and if there are any discharges from the 
nasal or aural cavities the affected mucosae must be appropriately treated. For 
eczema of the eyelids the white precipitate ointment will be most appropriate. In 
children a mask must be worn, more especially at night, to prevent irritation and 
infection from the finger-nails. 

Eczema manuum. This is frequently a most difficult affection to cure, more 
especially when it is dependent on the patient's occupation, as is the case with 
washerwomen, bakers, plasterers, etc. In so far as it is possible these sources of 
irritation must be removed, and in some cases rubber gloves can be worn while at 
work. The balsam-of-Peru ointment (No. 74, p. 138) or a tar paste (No. 75, p. 138) 
is a useful local application. Very chronic cases may require to be painted with 
the pure tar spirit (No. 10, p. 56) or pure tar. Eczema of the palms is a very fre- 
quent affection, the parts being hard, thickened, and fissured at the folds of the 



138 ILLUSTRATED SKIN DISEASES. 

skin. Here the thickened epidermis must be removed by friction with pumice-stone 
or by means of the salicylic plaster recommended by Unna, after which the ointment 
of ammoniated mercury or a tar preparation may be used. 

No. 74. Peru-Balsam Ointment. 



fy Bals. Peruv. 
Ac. salicyl. 
Petrolati 
Adip. lanse 
Pulv. zinci 
Pulv. amyl 



\ 

ox. > 

i ) 



tment. 




No. 75. 


Tar Paste. 


10 parts 
i part 


$ 


01. cadini . 
Pulv. zinci ox. 
Pulv. amyli . 
Petrolati 


io to 15 parts 

aa. 20 " 
ad. 100 " 


aa. 10 parts 









Eczema cruris. Here the best method is to use some mildly stimulating appli- 
cation, such as Lassar's paste (No. 2, p. 43), after thoroughly disinfecting the surface. 
The acuter cases can be treated with the various dusting powders (No. 18, p. 61, 
No. 64, p. 135) or powdered boracic acid. If varicosities exist, as is usually the case, 
a properly applied bandage must be worn continuously. In the chronic scaly cases 
support and protection of the surface with the glyco-gelatin application (No. 4, p. 43) 
is very useful. It must be melted in a water bath, and applied freely with a brush 
to the part after careful cleansing and disinfection ; bandages are applied before it 
has set ; and the dressing may remain in situ for from three to seven days. 

Eczema genitalium is often a very chronic and intractable affection. The parts 
must be supported and kept apart by means of pads of borated cotton, suspensories, 
and T-bandages. In the most acute cases the calamine lotion (No. 73, p. 137) or the 
boracic-acid plaster-mull should be employed ; in others a carbolized zinc or simple 
ointment is appropriate. Chronic eczema of the scrotum, with much thickening, 
requires the cautious use of tar or mercurial preparations, such as the white precipi- 
tate ointment, Bronson's mercurial ointment (No. 23, p. 64), or the tar paste (No. 
75, p. 138). Eczema of the anus requires attention to possible causes in the way of 
ascarides or hemorrhoids, with careful regulation of the diet and evacuations. A 
3- to 5-per-cent. carbolic-acid lotion, or water as hot as can be borne, applied to the 
anus immediately after each defecation will do much to relieve the itching. Lassar's 
paste (No. 2, p. 43) and the tar spirit or ointment (No. 22, p. 64, No. 45, p. 104) are 
useful applications. Van Harlingen recommends a carbolized almond-oil very 
highly. 

Eczema of the nails is a very chronic affection, in which the nails become rough, 
uneven, and marked with dark striae or dots. The various tar applications or the 
milder mercurial salves must be persistently used. 

Eczema barbae is of frequent occurrence; the affected surface is reddened and 
covered with yellowish-green crusts that mat the hairs together; and as the hair- 
sacs are usually affected, folliculitis and destruction of these structures usually occur. 



1 




COPYRIGHT BY E. B. TREAT 4 CO. , N. Y. 



PHOTOGRAVURE & COLOR CO., N. Y. 



ERYTHEMA MULTIFORME 

PLATE XLVII 



INI 

The : 

Ecz- 

. 

Lichen I 

I 



MA MULTIFOF 

■ 

I 

^rytheni;. 

p 

- 

• i 













ERYTHEMA ? 3ME 



INFLAMMATIONS. 139 

The parts must be shaved or epilated ; mere clipping of the hair will not suffice. 
The various sulphur or zinc salves and pastes (Nos. 24, 25, p. 64, etc.) or the diach- 
ylon salve (No. 71, p. 136) can then be employed. 

Eczema intertrigo must not be washed; the parts can be cleansed with warm 
olive-oil, and must be kept apart with pads of absorbent cotton. The various dusting- 
powders (No. 18, p. 6 1, No. 64, p. 135) or the boracic-acid lotion or ointment (No. 
29, p. 74) may be used. 

Lichen tropicus or prickly heat is a more or less acute papulo-vesicular eczema 
occurring on the body during the hot weather. It is best treated by means of alka- 
line lotions (No. 67, p. 135) or the dusting powders (No. 18, p. 61, No. 64, p. 135). 
The zinc- and lime-oils (Nos. 65, 66, p. 135) are also useful. 



ERYTHEMA MULTIFORME. 

Synonyms. — Erythema exudativum multiforme s. polymorphum, ery theme poly - 
morplie (Fr.). 

Definition. — An acute inflammatory disease, characterized by the appearance of 
reddish papules, tubercles, vesicles, or blebs of symmetrical distribution, and affect- 
ing by preference the backs of the hands and feet. 

Symptoms and Course. — After a prodromal period marked by a moderate febrile 
movement, there appear on the backs of the hands and feet, or on the palms and 
soles, and more rarely on other parts of the body, a varying number of slightly ele- 
vated, firm, reddish-violet papules, fading on pressure. This condition is known 
as erythema papulatum. In a few days the papules grow into tubercles perhaps 
\ of an inch in size (erythema tuberculatum). The centers then begin to flatten 
and fade out, and assume a characteristic bluish-red hue (erythema annulare). At 
the periphery, where the eruption is extending, the lesions preserve their elevated 
form and reddish tint. Adjacent patches may coalesce and form irregular figures 
known as erythema gyratum and erythema figuratum. More rarely the appearance 
of blebs gives us the form known as erythema bullosum. Herpes iris is the desig- 
nation given to a vesicular form of this erythema, in which new concentric rings of 
papulo-vesicles appear in the depressed purplish center of an annular erythema. 
These various forms, once looked upon as distinct diseases, are in reality merely 
stages of the same process with varying amounts of exudation. A case may go 
through several of them, and even show them simultaneously ; for multiformity is 
characteristic of the disease ; but usually one type only is present, and the common- 
est by far is the papular one. The malady occurs especially in the spring and the 
fall, and lasts for from four to six weeks. It happens at any age, and is somewhat 
more frequent in females than in males. The mucosas are occasionally affected. It 



140 ILLUSTRATED SKIN DISEASES. 

is prone to relapse, and usually reappears in its original type. It is occasionally 
complicated with purpura, acute articular rheumatism, and endocarditis. 

Etiology. — The cyclic course of erythema multiforme and its prevalence at certain 
seasons of the year lead us to believe that in some cases at least it is an infectious 
disease, though the etiological agent has not yet been discovered. It is sometimes, 
however, merely symptomatic, occurring with cholera, typhus, syphilis, and acute 
rheumatism, or after the ingestion of certain drugs. It is occasionally caused by 
local irritation, Kaposi having had a case in which the inunction of gray ointment 
always caused its appearance ; or reflexly, as in Lewin's case, in which it was caused 
by irritation of the urethra. 

Diagnosis. — Its typical course and location, the papules or tubercles whose red 
color is removable on pressure, and the absence of desquamation, are sufficient to 
characterize the disease. An eczema has exudation, scales, and crusts, and itches 
intensely. Urticaria has pale or pinkish fugacious elevations, with much itching and 
reflex irritability of the skin. A papular syphiloderm is copper- colored and not re- 
movable by pressure ; the palms and soles are usually involved, and other syphilitic 
symptoms are generally present. Prurigo has deep-seated colorless papules, begins 
in childhood, and itches intensely. Trichophytosis corporis is scaly in the center, 
and the parasite can usually be readily found. 

Pathology. — The process consists in an inflammation of moderate intensity of 
the upper portion of the corium, with vascular dilatation and some exudation and 
cell-infiltration. 

Prognosis. — This is always good, save when the erythema is symptomatic of or 
complicated with some one of the more serious maladies mentioned above. 

Treatment. — The cause must be removed when it can be found; and this is most 
likely to be possible when the erythema follows the use of some one of the drugs 
that react upon the skin, copaiba, quinine, antipyrin, etc. Rheumatism or any other 
coincident affection must be appropriately treated; and saline purges, tonics, etc., are 
useful adjuncts. The local treatment need only be of the simplest character, cala- 
mine lotion (No. 73, p. 137) or a cooling salve (No. 68, p. 135) or dusting powder (No. 
64, p. 135) being all that is required. 



HERPES. 

Definition. — An acute inflammatory eruption, characterized by the appearance 
of groups of pinhead- to small pea-sized vesicles on slightly reddened bases, and 
situated usually on the face or genitals. 

Symptoms and Course. — This very common affection begins with swelling and 
redness of the area affected, followed by the eruption thereon of small papules which 
rapidly become vesicular. The vesicles occur in groups of from six to twelve and 



INFLAMMATIONS. 



141 



are often confluent. In one or two days their contents become cloudy, and in a few 
days to a week they dry up into thin crusts, under which repair of the epithelium 
progresses. Slightly pigmented spots are left behind when the crusts fall off, which 
disappear without trace in a week or two more. Moderate itching and heat accom- 
pany the eruption. Scratching and re- 
moval of the crusts prolong it, and may 
even lead to superficial ulceration. 

Two chief varieties of herpes are en- 
countered as the eruption affects the face 
or the genital regions. Herpes facialis, 
s. labialis, s. febrilis, or fever-sore, occurs 
around the mouth and nose near the muco- 
cutaneous boundaries. The lips, cheeks, 
and alae nasi are most frequently affected. 
Vesicles may appear on the mucosae ; but 
here, on account of the delicacy of the epi- 
thelial covering, they soon lose their ves- 
icular form and appear as circular grayish 
or reddish eroded areas. Herpes progen- 
italis, s. preputialis, s. vulvarum, occurs on 
the glans penis, prepuce, labia majora, or 
nymphae. Its course is similar to the her- 
pes of the face, but it is very prone to re- 
cur at irregular intervals, and is liable to 
be prolonged and to ulcerate from the 
irritation caused by coitus or uncleanliness. 

Etiology. — Herpes occurs frequently 
in healthy individuals, and we are ignorant of its real cause. It is often seen in febrile 
internal diseases, pneumonia, malaria, and meningitis, in catarrhal affection of the 
mucous membranes, bronchitis, rhinitis, etc., and also after nervous disturbances. 

Pathology. — The inflammatory exudate is in the rete, and the amount of cell- 
infiltration varies with the intensity of the inflammation. The vesicles are multi- 
locular. 

Prognosis. — This is of course good; herpes facialis is short-lived, but herpes 
progenitalis is more obstinate and recurs frequently. The dangers of the possibilities 
of syphilitic inoculation must not be lost sight of in these latter cases. 

Diagnosis. — This is of great importance in the genital variety, where the differ- 
entiation between herpes, chancroid, and chancre must always be made. The 
groups of vesicles or the convex-bordered confluent erosions in the favorite locations 
are sufficiently characteristic. In chancroid the vesicle rapidly becomes pustular; 
a round, undermined sore with dirty base results from its rupture; it is painful, 




Fig. 71. — Herpes febrilis. 
From photograph by the author. 



142 ILLUSTRATED SKIN DISEASES. 

auto-inoculable, and is accompanied by the inflammatory bubo. Chancre has the 
induration and the characteristic hard, painless adenopathy. But it must not be 
forgotten that either or both may coexist with herpes, and that a definite opinion 
cannot be given in the case of chancroid for several days, and in that of chancre 
until the longest period of possible primary incubation has passed. 

Treatment. — In many cases none is necessary. The crusts should not be re- 
moved, and a mild dusting powder (No. 18, p. 61) or a rose-water ointment or cooling 
salve applied to the part (No. 29, p. 74, Nos. 68, 69, p. 135). Dermatol, iodoform, 
etc., may also be employed. A layer of absorbent cotton between glans and prepuce 
will serve to protect the parts. 

ZOSTER. 

Synonyms. — Herpes zoster, zona, ignis sacer, shingles, Giirtelrose, Fenerrose 
(Ger.), sona (Fr.). 

Definition. — An acute inflammatory disease of definite duration and course, 
characterized by the appearance of groups of vesicles on inflamed bases situated on 
the course of one or more of the cranial or spinal nerves, and accompanied by neu- 
ralgic pain. 

Symptoms and Course. — For a varying number of days the patient suffers from 
burning, itching, and neuralgic pains in the area of the skin that is about to be af- 
fected, with perhaps a moderate pyrexia and its accompanying symptoms. Exam- 
ination reveals nothing locally, save perhaps slight tenderness to deep pressure over 
the roots of the nerves that supply the skin of the part, or at the sensitive points of 
Romberg. Suddenly a circumscribed area of the integument becomes erythematous, 
and in a few hours is covered with a group or groups of minute papules, which rap- 
idly become vesicles. In thirty-six to forty-eight hours they have become pea-sized, 
and the serum has become milky or frankly purulent; by the third or fourth day 
adjacent pustules have usually coalesced to form blebs of varying size. If they are 
not ruptured the serum is absorbed, the blebs shrink, and by the end of the week 
the affected area is covered with crusts of shriveled epidermis, under which repair 
of the destroyed integument slowly takes place. If the pustules or blebs are rup- 
tured, excoriated or ulcerated surfaces are left behind, which heal in the course of 
the second or third week, often leaving behind depressed cicatrices, which are at 
first pigmented, and later white. 

While the first groups of vesicles are passing through these various stages other 
groups have appeared on other areas of skin, or even among the original set. The 
successive crops appear along the course of the nerve at intervals of a few hours or 
a few days, and each one runs its own independent course, irrespective of the older 
or younger groups around it. Thus we may have present at the same time a red 
and pigmented scar, representing the primary efflorescence ; excoriated surfaces with 




ZOSTER PECTORALIS. 




TYPOGRAVURE. 



COPYRIGHT BY E. B. TREAT 4 CO., N. Y. 



ERYTHEMA MULTIFORME. 



PLATE IV. 










■ 



em ; grou 

The m 
poussees st ccessh 

Zoster oca 

a case in ai i ■-• amples of it in 

very rat I election 

for the m rous 

individuals der- 

■ 

I re- 
ap- 
pare; 

cases ap; - in 

New York City in It is aim 

always unilater.- md 

I enter, Hen 
■ 
- encircle 

gainst the disease; but there are ex 

rated case I 

be the seat of sh 

st. 
are named according to tl i — zoster 

cial mention is z< 
uently accompanied by conji 
panophtha 'ruction of the eye, and even by a 

ier cases, when the inflammation is severe 
enough to I die diar white 

variety kno ! the inflammatory si 

isofsufficiei tanddi use gangrem 

The neuralgic pains tl 
severe, and th iv persist for aid months after its termination. Tumei 

tion of the lymphatic glands of the affe( a almost always occurs. 

Etiology.— Barensprung in 1862 first showed that the d 
dependent on an inflammation of the I the pos 

and spinal nerves, inflammat 

In other cases a peripheral neuri been foi number 

reported in connection with traumatisms, compressi< geal 

exudations, spinal 1 The prevalence of the d ds of 




'ECTORALIS. 



- 








COPYRIGHT BY E. B. TREAT 1 CO., N. Y. 



ERYTHEMA MULTIFORME. 



PLATE IV. 



INFLAMMATIONS. 



143 




Fig. 72. — Zoster patch. 

From photograph by the author. 



the semi-detached epithelium still covering them ; groups of coalescent bullae ; as- 
semblages of pustules and vesicles large and small; and reddened areas where the 
primary erythema has but just appeared. The malady advances " schubweise" a 
poussees successives. 

Zoster occurs at all ages, but is commonest in childhood. Lomer has reported 
a case in an infant four days old, and examples of it in elderly individuals are not 
very rare in our clinics. It shows no predilection 
for the weak or debilitated ; healthy and vigorous 
individuals are frequently attacked. It is a moder- 
ately rare disease. My own statistics show thirty- 
two cases in eight thousand consecutive cases in 
private and public practice. It is seen most fre- 
quently in the spring and fall ; sometimes it is ap- 
parently epidemic, a comparatively large number of 
cases appearing at the clinics ; such was the case in 
New York City in the autumn of 1895. It is almost 
always unilateral, but double zoster does occur, and 
cases have been reported by Carpenter, Henoch, 
and others. It is a superstition of the laity that if 
shingles encircles the body it is necessarily fatal. Almost invariably one attack 
protects against the recurrence of the disease ; but there are exceptions, and in 
Kaposi's celebrated case there have been eleven separate attacks. 

Any portion of the body may be the seat of shingles, but I have found it most 
frequently by far on the upper extremities and chest. 

For descriptive purposes the zosters are named according to their location — zoster 
facialis, cruralis, etc. ; but the only localization that deserves especial mention is zoster 
ophthalmicus. This is a severe affection and is frequently accompanied by conjunc- 
tivitis, corneal ulceration, panophthalmitis, destruction of the eye, and even by a 
fatal phlebitis and meningitis. In other cases, when the inflammation is severe 
enough to lead to the diapedesis of red as well as white blood-cells, we have the 
variety known as zoster hemorrhagicus. Very rarely indeed the inflammatory stasis 
is of sufficient extent and duration to cause gangrene, giving us zoster gangrenosus. 

The neuralgic pains that precede and accompany the disease are frequently very 
severe, and they may persist for weeks and months after its termination. Tumefac- 
tion of the lymphatic glands of the affected area almost always occurs. 

Etiology. — Barensprung in 1862 first showed that the disease was in some cases 
dependent on an inflammation of the ganglia of the posterior roots of the cerebral 
and spinal nerves, inflammatory and hemorrhagic foci being found in these structures. 
In other cases a peripheral neuritis has been found. A number of cases have been 
reported in connection with traumatisms, compression by tumors, pachymeningeal 
exudations, spinal caries, etc. The prevalence of the disease at certain periods of 



144 ILLUSTRATED SKIN DISEASES. 

the year has led Wasielewski to claim that it is an infectious disease, further evidence 
in that direction being afforded by the immunity from recurrence which one attack 
seems to confer. Probably an infection, like the other causes mentioned, may be the 
injury that starts the neuritis that is at the root of the disease. 

Pathology. — Cell-multiplication and serous exudation occur in the tissue of the 
coriura, and the latter raises the corneous layer and the upper rete-cells into a 
multilocular vesicle. 

Diagnosis. — The vesicular eruption, the peculiar location following the course of a 
nerve-trunk, with the accompanying neuralgia, prevent any difficulty in this direction. 

Prognosis. — This is good when there is no serious disease, such as spinal caries 
or carcinoma, behind the zoster eruption. In zoster ophthalmicus our prognosis must 
be guarded. In many cases an obstinate neuralgia is left behind. 

No. 76. Duhring's Morphine Collodion. No. 77. Laudanum Ointment. 

# Morph. sulph. 
Collod. flexile 



i part 


R Tr. opii 


. 


20 parts 


ioo parts 


Ac. carbolic. ■ 


. 


i part 




01. amygd. dulc. 


. 


20 parts 




Adip. lanae . 


. 


• 300 " 



Treatment. — Zoster is a self-limited disease, and we cannot influence its course. 
For the neuralgia, quinine, antipyrin, and phenacetin may be given in large doses ; 
and sometimes we are compelled to have recourse to morphine, either by the mouth 
or hypodermically. After the eruption has gone, arsenic in the form of the Asiatic 
pill (No. 6, p. 46) or as Fowler's solution is indicated. Locally we must protect and 
soothe the inflamed surfaces. A 20-per-cent. mixture of chloroform and olive-oil 
or a 5- to 20-per-cent. cocaine salve will be found useful. Duhring recommends 
morphine in collodion (No. 76, p. 144) painted on the part. I usually employ a lau- 
danum ointment (No. yy, p. 144). The bitter tonics, iron, and cod-liver oil are gener- 
ally required after the disease has run its course. 



DYSIDROSIS. 

Synonyms. — Pompholyx, cheiropompholyx. 

Definition. — An acute inflammatory disease affecting the palms and soles, and 
characterized by the appearance of deep-seated grouped vesicles filled with a clear 
serum, later becoming opaque, and disappearing by rupture or absorption. 

Symptoms and Course. — The affection is most commonly seen on the sides of the 
fingers and on the palms, and less often on the toes and soles ; in rare instances other 
portions of the integument are affected. There appear smaller or larger, deep-seated, 
sago-grain-like vesicles arranged in groups and seated on a slightly reddened base. 
The clear serum with which they are filled becomes cloudy in a few days, and the 




COPYRIGHT BV E. B, TREAT & CO., N. Y. 



PHOTOGRAVURE A COLOR CO., N. Y. 



PEMPHIGUS 



PLATE XIV 









I 

- 



Etiology.- 

Patholog-, 

a 












- 



. 






ap- 



chro; 






i 

I 
- 

.eddene' 



e 
beco 




PEMPHi' 



INFLAMMATIONS. 145 

coalescence of adjacent vesicles may form larger blebs. In the course of a number 
of days they dry up or rupture, and the process ends with some exfoliation of the 
epidermis. Slight burning and itching accompany the eruption. The process may 
be a chronic one, and be prolonged for weeks and months by the appearance of 
successive crops of vesicles. 

Etiology. — Dysidrosis occurs most often in nervous women, and more especially 
in those suffering from dyspepsia. We are ignorant of the real cause of its appear- 
ance. 

Pathology. — According to Robinson, this consists in an obstruction of the sweat- 
duct and accumulation of fluid in the upper layers of the rete. A cystic degenera- 
tion of the sweat-glands has been noted by some observers. 

Diagnosis. — The affection could only be confounded with a vesicular eczema, 
and it can readily be distinguished from this by the peculiar location and the absence 
of any tendency to rupture or form crusts or weeping surfaces. 

Prognosis. — The malady is troublesome, but otherwise harmless. 

Treatment. — The nervous and dyspeptic conditions underlying the malady must 
be attended to. Locally the 10- to 20-per-cent. collemplastrum of salicylic acid 
can be applied to the part. The tar spirit (No. 10, p. 56) is useful in some cases, 
and all the ordinary antipruritic remedies (p. 56) may be employed. 



PEMPHIGUS. 

Synonym. — BlasenansscJilag (Ger.). 

Definition. — An acute or chronic inflammatory disease, characterized by the ap- 
pearance of successive crops of bullae of varying size, containing a clear or cloudy 
serum, seated on slightly inflamed bases, and accompanied or not by constitutional 
symptoms of varying intensity. 

Symptoms and Course. — Bullous eruptions occur in various diseases (syphilis, 
urticaria, leprosy, etc.) ; but in pemphigus they constitute the essential phenomenon 
of the malady. We distinguish two chief forms : pemphigus vulgaris, the com- 
moner acute or chronic variety, and pemphigus foliaceus, a rarer and more serious 
disease. 

In pemphigus vulgaris, with or without a prodromal fever, there appear on one 
or more portions of the integument, most frequently on the lower extremities and 
exceptionally upon the mucosae, wheal-like erythematous spots that soon develop 
into the blebs that are characteristic of the disease. The bulla? are oval or rounded, 
with tense or lax walls, and are filled with a serum that is at first clear, but later 
becomes cloudy and purulent or even mixed with blood (pemphigus hemorrhagicus). 
Their size varies from that of a lentil to that of a large egg ; they are seated on 
slightly reddened bases; there may be one only (pemphigus solitarius) or a hundred 



146 



ILLUSTRATED SKIN DISEASES. 



r 







or more; and they show no tendency to grouping or regularit)- of arrangement. 
They grow for several days, and adjacent ones may coalesce ; in a week or so they 
have attained their full size, and retrogression commences. If the bullae are not 

ruptured the serum 
begins to disappear 
by absorption or 
evaporation ; the 
tense walls of the 
blebs become lax 
and shriveled ; and 
they dry up into 
scabs, under which 
regeneration of the 
epidermis takes 
place. The scabs 
fall off in time, leav- 
ing a temporary 
pigmentation, but 
no loss of tissue, be- 
hind. There may 
be only one out- 
break, or successive 
crops of the erup- 
tion appearing at irregular intervals may prolong the malady for several months. 
The subjective symptoms are usually limited to slight itching and burning. In ac- 
cordance with its course, we have an acute and a chronic form of the disease. 

Pemphigus vulgaris acutus is a rare affection, especially in adults ; in children it 
assumes the form of an infectious disease and occurs epidemically. The outbreak of 
the eruption is accompanied by considerable fever and constitutional disturbance, and 
successive crops of blebs appear at frequent intervals for some two or three weeks. 
Any portion of the integument, and even the mucosas, may be affected ; but the 
backs of the hands and feet are most frequently involved. It is of importance from 
a diagnostic point of view that the palms and soles usually escape. As a rule the 
disease terminates in recovery, but some cases run a malignant course and end fatally. 
In the case of a woman sixty years of age, that I saw in the winter of 1895, the 
eruption began with moderate prodromal symptoms, and a few blebs appeared in the 
axillae and on the chest; successive crops of vesicles came out almost daily, until in 
a week the entire body was covered with various-sized confluent and discrete bullae 
and excoriated surfaces; the patient took to her bed and succumbed to an intercur- 
rent pneumonia two weeks later. 

Pemphigus vulgaris chronicus is the common form of the affection. The number 



Fig. 73. — Acute Pemphigus. 
From photograph by the author. 





TYPOGRAVURE. 



COPYRIGHT, 1902, BY E. B. TREAT 4 CO., N. ' 



ZOSTER SACRO-CRURALIS. 



PLATE Lll. 



INFLAMMATIONS. 



147 




of bullae present at any one time is very various ; there may be only one, or an in- 
definite number may be scattered over the body. The individual blebs last but a 
few days ; they disappear by rupture or absorption and evaporation, leaving scabs 
covering a red and 
secreting skin. The 
outbreaks occur ir- 
regularly, and va- 
rious stages of the 
lesions are usually 
present at one and 
the same time. As 
a rule the mal- 
ady runs a benign 
course, especially 
in children ; the 
general condition 
remains good, there 
is little or no fever, 
and the local symp- 
toms are compara- 
tively slight. In 
rare instances it as- 
sumes a malignant 
form. The bullae 
are numerous, run 
a rapid course, and 
frequently coal- 
esce ; and when 

they rupture, thick crusts covering suppurating surfaces are left behind. The itch- 
ing and burning are great, sleep and nutrition are interfered with, and the patient 
dies of exhaustion or from intercurrent disease of the internal organs. In the severe 
form of the disease known as pemphigus diphtheriticus, the denuded areas left when 
the bullae rupture become covered with a dense grayish- white pseudo-membrane ; 
and in that known as pemphigus vegetans, frambcesia-like masses of granulations 
grow from them, which are very liable to undergo superficial gangrene. 

Pemphigus foliaceus often begins as the ordinary form of the disease, by the 
long continuance of which the patient has been debilitated and worn out. The bullae 
are small, with flabby walls, and have milky or reddish contents. After rupture and 
escape of their fluid contents, reddened, excoriated, and weeping surfaces are left 
behind, on which the epidermis shows no tendency to regeneration. The remains 
of the blebs with the dried secretion form partially detached threads and flakes. In 




Fig. 74. — Pemphigus Vulgaris. 

From photograph by the author. 



148 ILLUSTRATED SKIN DISEASES. 

advanced cases the entire integument may be affected, and the palms and soles are 
especially liable to be involved. No bullae may be present ; the skin is dark red, dry 
or moist, and more or less covered with scales and crusts. The hairs become dry 
and brittle and fall out, and the buccal, conjunctival, and other mucosae may become 
affected. The general symptoms are marked ; there is fever, diarrhea, pain, and 
sleeplessness, and the patient finally dies of exhaustion. 

Pemphigus pruriginosus is another malignant form of the disease, which is marked 
by continuous and intense itching, with pigmentation of the skin in consequence of 
the scratching that ensues. It is usually associated with nervous disturbances. 

Etiology. — Pemphigus occurs much oftener in children than in adults ; but we are 
entirely in the dark as to its nature and cause. Low and depressed states of the 
general system, such as result from overwork, insufficient nutrition, etc., seem to 
favor its development. It is neither infectious nor communicable. Parasitic organ- 
isms have been found in the blebs by Spillman, Vidal, and Gibier, but their etiological 
relationship to the disease has not been proved. 

Pathology, — The fluid in the blebs is serous and alkaline, and contains a few 
leucocytes, epithelial and red blood-cells, etc. It lies between the stratum granu- 
losum and the stratum lucidum, the covers of the single-chambered bullae being 
chiefly composed of the corneous layer. 

Diagnosis, — The presence of bullae alone is not sufficient for the diagnosis of 
pemphigus, since they occur in a number of other diseases; but it is rarely difficult 
to form a definite opinion. The scattered, moderately tense, thin- walled blebs, ap- 
pearing in successive crops, together with the general symptoms, are usually suffi- 
ciently characteristic. The same may be said of the heaped-up layers of shredded 
epidermis and the general reddening of the integument in the foliaceous form. Ecze- 
ma is rarely bullous; the vesicles are smaller, and weeping surfaces, crusts, and other 
symptoms of catarrhal inflammation of the skin are present. Herpetiform dermatitis 
is distinguished by its polymorphism, erythematous areas, the presence of papules 
and vesicles, by its grouped herpetic arrangement, and by the itching. Bullous urti- 
caria is rare, runs a very acute course, and has wheals and intense itching. Erythema 
multiforme is acute and does not relapse, appears in rings, and is seated usually on the 
arms and the backs of the hands and the lower limbs. Impetigo contagiosa has doubt- 
less often been mistaken for pemphigus ; but its location on the face and hands, slow 
course, and the presence of other cases in the same family, house, or school, should 
be sufficient to prevent error. It is not likely that scabies, with its location on the 
hands, arms, and genitals, its polymorphism, its characteristic tracks, and the history 
of contagion, will be mistaken for a pemphigus, even if bullae are present. An ex- 
foliative dermatitis may resemble a pemphigus foliaceus ; but the scales are larger 
and thinner, the skin on which they are situated is reddened and dry, there are no 
bullae, and the malady does not advance in successive crops. The commonest source 
of error is probably a bullous syphiloderm ; but here the individual lesions are 




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PHOTOGRAVURE 4 COLOR CO., N. 



IMPETIGO 



PLATE XLVI 















Trei 






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daily. 









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pruriginos 

as recommer. 



Tie. 



DERMATJ HTIFORMIS. 



OR CC. 






PUAT? 



INFLAMMATIONS. 149 

of slow course, dry up into thick, greenish-brown crusts under which ulceration 
takes place, and other evidences of lues are usually present. 

Prognosis. — This should be a cautious one, for even the benign forms of pemphi- 
gus may become malignant in the course of time. In pemphigus foliaceus and 
vegetans it is always bad; they almost always end fatally, though the patients may 
survive for a long time. In a general way, the laxer the blebs, the greater the ad- 
mixture of red blood-cells with their serum, and the more rapid the appearance of 
the successive crops, the worse the prognosis. 

Treatment. — This must necessarily be almost entirely symptomatic. Any inter- 
nal disease that may be present must be appropriately treated, and rest, abundant 
nourishment, fresh air, and general hygienic measures are of the greatest importance. 
Arsenic has been lauded by Hutchinson as almost a specific for the disease, and is 
undoubtedly of benefit. It may be given in the form of the Asiatic pill (No. 6, 
p. 46) or as Fowler's solution, 3 to 15 drops administered well diluted after meals. 
Sherwell has gotten good results from the use of linseed-oil both externally and in- 
ternally ; I ounce may be administered in milk three times daily. 

No. 78. Unna's Soft Zinc Paste. 

ft 01. lini 
Aq. calcis 
Zinci ox. 
Cretan . . . . . aa. p. e. 

The local treatment should consist of the puncture of the blebs, and the free use 
of one of the dusting powders (No. 18, p. 61, No. 64, p. 135) or a mild ointment, 
paste, or oil (No. 26, p. 70, No. 29, p. 74, No. 66, p. 135, No. 69, p. 135, etc.). Unna 
recommends a soft zinc paste (No. 78, p. 149). Sulphur baths (p. 41) may be tried. 
In bad cases the continuous bath recommended by Hebra is perhaps the most effica- 
cious remedy that we possess, and contributes greatly to the comfort of the patient. 
It may be employed continuously for days, weeks, or even months, if proper arrange- 
ments are made for the renewal of the water, its maintenance at an even temperature, 
and the comfort of the patient therein. For pemphigus foliaceus, if extensive, it is 
the only method that promises relief. In pemphigus vegetans a vigorous curetting 
of the affected spots, followed by the free application of the tincture of iodine, has 
done very well in some cases. In pemphigus pruriginosus the bichloride bath (3i to 
the bath) may be cautiously used. In any case linseed-oil as recommended by 
Sherwell may be freely employed. 

DERMATITIS HERPETIFORMIS. 

Synonyms. — Dermatite polymorpJie prurigineuse a pousse'es successives (Fr.), hy- 
droa, hydroa herpetiforme. 



150 ILLUSTRATED SKIN DISEASES. 

Definition. — A recurrent polymorphous eruption, most often of vesicular type 
and herpetic arrangement, but showing also macules, papules, and bullae. 

Symptoms and Course. — This disease, first recognized by Duhring, is characterized 
by the variety of its lesions to such an extent that Hyde recommends dermatitis 
multiforme as a more appropriate name. Its exact relationship to hydroa, herpes 
gestationis, and pemphigus is not yet settled. With a preliminary fever, rigors, 
malaise, and gastric disturbance, there occur flat, slightly elevated, irregularly defined 
macules on a limited area of the body, which soon develop into vesicles or bullae 
with cloudy, hemorrhagic, or purulent contents. They are arranged in groups or 
concentric rings. In about a week the vesicles rupture or dry up, and the crusts 
leave a pigmented surface behind when they fall off. New groups appear from 
time to time, run the same course, and thus prolong the disease for weeks and 
months. Any portion of the body may be affected, but successive crops usually 
appear at the margins or in the neighborhood of the primary eruption, and the dis- 
ease is usually limited to a definite area of the body. The mucosae may be affected ; 
and here the eruption appears as a group of irregular superficial ulcerations, with 
dirty and unhealthy-looking bases. Intense itching is a marked feature. The mal- 
ady occurs in both sexes and at all ages. 

Etiology. — This is as yet entirely unknown. 

Diagnosis. — The polymorphous nature of the eruption, its herpetic arrangement, 
the intense itching, the relapses at irregular intervals, and the good condition of 
the general health will serve to distinguish the malady from pemphigus, with which 
it has been long confounded. 

Prognosis. — The malady is obstinate and of long duration, but is not accompanied 
with any danger. 

Treatment. — Duhring recommends arsenic given persistently, and antipyrin has 
done good in some cases. Externally, medicated baths or the various antipruritic 
applications recommended for pruritus, eczema, etc., may be employed. 

Impetigo, formerly considered a distinct disease, is to be regarded rather as a 
symptom, and has been proved by Bockhardt to be directly due to infection of the 
skin with pus organisms. By means of inunctions and inoculations with cultures of the 
staphylococcus pyogenes albus and fiavus he caused the appearance of large single- 
chambered pustules seated on slightly inflamed bases. This occurs in a variety of 
conditions when purulent processes are present in the person affected or those 
that he comes in contact with. There appear one or a number of isolated vesicles 
or vesico-pustules, which finally develop into small, rounded blebs filled with 
pus. They dry up into yellow superficial crusts, which leave a reddened and 
slightly pigmented surface behind when they fall off. The malady is self-limited 
and runs its course in two or three weeks. 




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PHOTOGRAVURE 4 COLOR CO., N. Y. 



IMPETIGO CONTAGIOSA 



PLATE XXII 



INFLAMMATIONS. 



151 



IMPETIGO CONTAGIOSA. 

Synonym. — Porrigo contagiosa. 

Definition. — An acute inflammatory contagious disease, marked by the appear- 
ance of one or more isolated vesicles or pustules, drying up into yellow adherent crusts. 

Symptoms and Course. — 'With or without febrile disturbance, there occurs an 
eruption of circumscribed, small, thin-walled vesicles, which soon enlarge in size and 
become distinctly pustular. 
Umbilication is occasionally 
present. After persisting for 
a few days they dry up 
into bright-yellow adherent 
crusts, looking, as Tilbury 
Fox says, as if stuck on to 
the skin. Adjacent pustules 
and crusts may coalesce to 
form larger affected areas ; 
but they are always sharply 
limited, and the surrounding 
skin and that between the 
lesions are not affected. In 
the course of two or three 
weeks the crusts fall off, leav- 
ing a reddened and slightly 
pigmented skin behind. Nei- 
ther ulceration nor scarring 
occurs. Successive crops of 
pustules appear from time to 
time, either among the older 
crusts or on other places, and 
thus the disease may be pro- 
longed for weeks. The sub- 
jective symptoms are con- 
fined to slight itching. The 
seat of the malady is usu- 
ally on the face around the 
mouth, chin, and nose ; the 
backs of the hands are not 
infrequently affected, and 

occasionally the pustules appear on the neck, buttocks, and other portions of the 
body. The mucosae are sometimes involved. The malady is seen almost exclusively 




Fig. 75. — Impetigo contagiosa. 
From photograph by the author. 



152 ILLUSTRATED SKIN DISEASES. 

in children ; it is contagious, and appears in epidemics, of which the very severe one 
on the island of Riigen in 1885 is a well-known example. Localized epidemics 
occur every fall, many cases occurring in the same tenement-house, street, or school. 
It is far more frequent among the poor, where the conditions of uncleanliness, close 
contact, etc., necessary for its development, are most often found. 

Etiology. — Impetigo contagiosa is most probably due to direct local infection 
with pus-cocci. It is both auto-inoculable and inoculable on others. 

Pathology. — The pus collections are covered with epidermis ; the corium is not 
involved, and cicatrization does not result. 

Diagnosis. — The discrete and isolated pustular lesions or adherent yellow crusts, 
the absence of surrounding inflammation, and the inoculability will serve to distin- 
guish the disease. It is liable to be confounded with a pustular eczema of the face; 
but here the surrounding inflammation, the weeping surfaces, the absence of discrete 
lesions, and the history of contagion should suffice to prevent mistake. 

Prognosis. — This is good ; the malady ends spontaneously in from two to three 
weeks. 

Treatment. — The crusts should be softened with olive-oil and removed, and the 
surface of the skin below treated with Lassar's salicylic-acid paste (No. 2, p. 43). 
Further contagion may be avoided by cleanliness, together with a daily sponging of 
the faces and hands of the children with a mild bichloride or other antiseptic lotion. 

DERMATITIS EXFOLIATIVA. 

Synonym. — Pityriasis rubra. 

Definition. — A general inflammatory disease of the skin, characterized by uniform 
deep redness and an abundant, large , thin-scaled desquamation. 

Symptoms and Course. — The malady begins with the appearance of red scaly 
patches, which rapidly extend and coalesce until the entire integument is affected. 
The skin is uniformly and deeply reddened, but dry and shiny, and is covered with 
thin, papery, whitish scales. On the face these scales are small, but on the trunk 
and limbs they are larger and may be an inch or more in size. They are attached 
at their centers, but free at the margins, and they frequently overlap more or less 
like the shingles on a roof. The amount of scaling may be very large, even up to 
one or two pints daily, and heaps of scales fall out of the patient's clothing when he 
removes it. The nails become opaque and fissured, or are raised from their bases 
by the collection of epithelium beneath them. The hair becomes thin and falls out. 
On the palms and soles the epidermis may fall off 01 masse, like a cast. The red- 
ness of the skin under the scales is diffuse and even, and besides this and the scaling 
there are no dermic lesions. The subjective symptoms are confined to itching or a 
feeling of tension of the skin. In mild cases there are no constitutional symptoms; 
but in the severer ones the general atrophy of the skin that occurs in the course of 




TyPOGRAVURE. 



COPYRIGHT, 1903, BY E. B. TREAT A CO., N. Y. 



DERMATITIS EXFOLIATIVA. 



PLATE VII. 



INFLAMMATIONS. 153 

time causes stiffness and disability, curvature of the fingers, ectropion, etc., and the 
patients may die of general marasmus or tuberculosis of the internal organs. 

Etiology. — The cause of the disease is unknown ; it is supposed to be dependent 
on tuberculosis. 

Pathology. — The malady is essentially a chronic dermatitis, which is at first 
superficial, but later involves all the structures of the skin. There is a general cell- 
infiltration, and finally a formation of new connective tissue with subsequent atrophy. 
The skin shrinks, the papillae and the glandular structures are destroyed, and the 
entire integument becomes too small for the body. 

Diagnosis. — Exfoliative dermatitis is characterized by the rather sudden onset, 
the diffuse dry redness, the scaliness, and the absence of any other forms of efflo- 
rescence. A general psoriasis may resemble it ; but it never covers the body so en- 
tirely, and patches of normal skin will be seen somewhere ; and the heaped- up silvery 
scales, with bleeding puncta beneath them, are distinctive. Pemphigus foliaceus 
has lax blebs, and dirty fatty scales situated on an eroded granular or secreting base. 
In universal eczema we have the thickened skin, small scales, and a polymorphous 
eruption — papules, vesicles, crusts, and weeping surfaces. 

Prognosis.— This is always doubtful. The German authorities regard it as uni- 
formly bad, but our experience here hardly confirms this view. Generalized cases 
usually terminate fatally, but less extensive ones recover. 

No. 79. Salicylic- Sulphur Paste. 

Ix Ac. salicyl. ... i part 

Sulph. depur. ... 5 parts 

Petrolati . . . 25 " 

Zinci oxidi 

Amyli . . . . aa. 10 " 

Treatment. — We have not much control over the course of dermatitis exfoliativa. 
Care of the general health and the adoption of all means possible to promote general 
nutrition must be our main reliance. Arsenic has been recommended to be given 
as in psoriasis. Frequent warm baths are useful, as is the external and internal use 
of cod-liver- and linseed-oils. Painting the affected area with tar spirit (Xo. 10, 
p. 56), followed by a prolonged warm bath, with the subsequent use of the salicylic- 
sulphur paste (No. 79, p. 153), has been recommended. 

PSORIASIS. 

Synonym. — ScJi uppc nflccJi tc ( G e r . ) . 

Definition. — A chronic inflammatory disease of the skin, characterized by the 
formation of red, dry, easily bleeding, infiltrated patches, covered with whitish or 
grayish, glistening, heaped-up scales. 



154 



ILLUSTRATED SKIN DISEASES. 



Symptoms and Course. — This very 
common skin affection begins uniformly 
with the appearance of a number of 
small, red, slightly elevated, and sharply 
denned papules, each capped with a 
minute silvery scale. They grow slowly 
by peripheral extension, the scaling and 
elevation both becoming more marked 
as the papules increase in size. Adja- 
cent ones may coalesce so as to form 
irregular figures or larger areas with a 
thickened, infiltrated skin, which tends 
to fissure and crack at the joints and 
natural folds. The color of the psoriatic 
spots themselves is pale red or a dirty 
yellowish red, being more livid on the 
lower extremities ; but it is more or less 
masked by the heaped-up scales that 
cover the efflorescences, and if the scales 
are permitted to accumulate the color of 
the eruption is white and silvery. The 
scales are peculiar, being very abundant 
and rapidly formed ; so that when the 
disease is extensive the patient's under- 
clothing may be so full of them that they 
fall out in showers when he removes it. 
They owe their white and glistening ap- 
pearance to the presence of air between 
the lamellae of the dried-up epithelial 
cells. When the scales are removed 
from a spot by scratching, a number of 
minute bleeding points appear ; these 
are the scratched-off tops of the con- 
gested papillae of the skin. The appear- 
ance is characteristic, and is of impor- 
tance diagnostically. The size and shape 
of the individual lesions vary greatly ; 
so also does their number ; there may be 
Fig. 76.— Psoriasis guttata. oru y a f ew small papules, or one or more 

Case of Dr. Ludwig Weiss. From photograph by ihe author. larger areas, or there may be thousands 
of individual lesions covering the entire body. The extensor surfaces of the limbs 





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PHOTOGRAVURE & COLOR CO., N. V. 



PSORIASIS 



PLATE XVII 






r i - 













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PSORIASIS 



INFLAMMATIONS. 



155 



are the seat of election of the psoriatic eruption, the flexor surfaces being either free 
or, at all events, less extensively affected. The trunk, genitals, and scalp are fre- 
quently covered, but the face is rarely involved. The palms and soles are almost 
always free ; in the rare cases in which they are affected there is diffuse thickening of 
the tissues, with scaling, and the diagnosis from a syphiloderm is both important and 
difficult. 

The disease occurs most often between the sixth and the twentieth year ; it is 
very rare in early childhood, though Elliot has recorded a case at the age of eighteen 
months. Its course is very 
variable, but it is essential- 
ly chronic. The majority 
of cases last for months or 
years, and many persist for 
life. The individual spots 
may slowly grow to a cer- 
tain size and then remain 
unchanged for an indefi- 
nite period, or they may 
undergo retrogressive 

changes and new ones ap- 
pear to take their place. 
At times and from un- 
known causes, the disease 
may almost or entirely dis- 
appear ; but many patients 
are never quite free from 
it and suffer from attack 
after attack at varying in- 
tervals. When involution 
begins the faint red border 
around the patch becomes 
pale, the scaling lessens 
and stops, and the redness 
and elevation slowly subside. In the larger spots this process frequently begins in 
the center, while the disease is still progressing at the margins ; and thus the vari- 
ous circinate and gyrate forms of the disease are caused. 

Psoriatic patients are usually robust, and even in the most extensive generalized 
cases the general health is but little affected. The only subjective symptom, if any 
is present at all, is a very moderate amount of itching. The hairs are usually not 
affected, even when the scalp is the seat of the disease; in very chronic cases, 
however, their nutrition is finally impaired and they fall out. The nails, on the 




Fig. 77. — Psoriasis diffusa. 
Case of Dr. Louis Fischer. From photograph by the author. 



156 ILLUSTRATED SKIN DISEASES. 

other hand, are frequently involved and may be the sole seat of the disease. Small 
white puncta appear in the lunula and gradually spread, the nail finally becoming 
fissured, furrowed, dull, and scaly. The mucosae are never affected, the so-called 
psoriasis buccalis being a leucoplacia due to syphilis, lichen ruber, etc. 

In accordance with the form and the extent of the eruption, we have certain 
subvarieties of the disease. When there are many pinhead-sized efflorescences we 




Fig. 78. — Psoriasis nummularis. 
After Van Haren-Noman 

have psoriasis punctata ; this is rather rare as an independent variety, for although 
all forms begin as puncta, they do not usually remain so long. Psoriasis guttata 
has larger lesions, looking like drops of mortar flung upon the skin. In psoriasis 
nummularis the spots are coin-sized. Psoriasis gyrata, figurata, and serpiginosa are 
formed by the coalescence of guttate and nummular lesions. Psoriasis annularis is 
ring-shaped, retrogression having occurred in the centers of the nummular areas. 
In psoriasis diffusa the patches are large, irregular, and greatly infiltrated. In 
psoriasis universalis the entire body is affected ; it is uniformly red, and is covered 
with scales that are rapidly cast off and regenerated ; it is frequently difficult to 
distinguish from dermatitis exfoliativa. Kobner has called attention to an artificial 
form of the disease, which can sometimes be produced in a psoriatic patient by a pin- 
scratch or other lesion. 

Psoriasis has but few complications. Eczema is the commonest of these, and is 
usually caused by too vigorous treatment. Seborrhea capitis is also seen. 

Etiology. — We know very little of the causes of psoriasis. It occurs at all ages, 
save in young children, and in all conditions of life. It is undoubtedly hereditary ; 
in a very large number of cases a history of its existence in the family can be ob- 
tained. The claims of various observers to have discovered a parasitic etiological 
factor have not been confirmed. 

Pathology. — In spite of the great amount of labor that has been expended on 
this subject, there is some doubt as to the exact nature of the process. Apparently 




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INFLAMMATIONS. 



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it is an inflammation of moderate intensity of the upper corium, with increased 
development of the rete, cellular infiltration around the vessels, and an enormous 
increase of the corneous layers. 

Diagnosis. — The primary efflorescence of the disease is characteristic, consisting 
of bright, shiny, dry scales on a circumscribed reddened base, and showing bleeding 
puncta when the scales are removed. This, with its seat on the flexor surfaces, the non- 
involvement of the palms and soles, the 
slio-ht itchinsr the absence of moisture 
and of falling of the hair, the chronic 
course and frequent relapses, forms a 
picture that is distinctive. It must be 
differentiated from : (a) chronic squa- 
mous eczema, which often resembles 
psoriasis closely, especially upon the 
legs ; but eczema has no sharp boun- 
daries, has serous exudation and crust- 
ing, itches greatly, is seated by prefer- 
ence on the flexor surfaces, and its scales 
are comparatively few, grayish, and 
sticky, (b) Seborrhea, which is a dif- 
fuse disease of the scalp, is compara- 
tively pale and non-indurated, and has 
scales that are dirty gray and fatty. 
(c) Lupus erythematosus, which has 
gray adherent seborrheal scales, with 
processes projecting from their under 

surfaces that fit into the dilated orifices of the sebaceous glands, shows central atrophy 
of the skin and destruction of the hair when the scalp is involved, and is commonest 
on the face, (d) Lichen planus has lesions that are polygonal, waxy, and shiny; 
they are of a dull red color, show fine sparse scales and no puncta. (e) A squamous 
syphiloderm is often difficult to distinguish from a psoriasis. The lesions are more 
infiltrated, however; they are copper-colored, non-symmetrical, less scaly than those 
of psoriasis ; they last only a short time ; and other lesions of syphilis are almost 
always present. (/) Dermatitis exfoliativa, as above stated, may closely resemble a 
generalized psoriasis; but, however extensive this latter disease may be, there are 
always areas where discrete psoriatic lesions are visible, while the dermatitis affects 
the entire surface uniformly ; the history of the disease will also help us to form an 
opinion. 

Prognosis. — This is good as to life and the general health, but bad as to the cure 
of the disease. The psoriatic spots can be removed and the body cleaned, but the 
malady will certainly return sooner or later. 




Fig. 79. — Psoriasis gyrata. 
From photograph by the author. 



15S ILLUSTRATED SKIN DISEASES. 

Treatment. — General hygiene and tonics are sometimes useful, though the health 
of these patients is usually good. Robinson recommends colchicum and potassic 
acetate (No. 80, p. 158) in gouty and plethoric subjects. Of the numerous internal 
remedies employed for the disease, only two or three deserve mention here. The 
most useful is undoubtedly arsenic ; it may be given as Fowler's solution with the wine 
of iron, as recommended by Duhring (No. 81, p. 158), or more conveniently as the 
Asiatic pill (No. 6, p. 46). It must be persisted in for a long time in gradually in- 
creasing doses up to the limit of toleration; and from 500 to 1000 pills must some- 
times be taken before a decided effect is observed. Fowler's solution given subcu- 
taneously, 10 minims of a i-per-cent. solution in distilled water, is of value in obsti- 
nate cases. The iodide of potash, given in gradually increasing doses up to 150 
grains and administered in milk after meals, has given good results in some instances. 
Ichthyol and arsenic in combination (No. 82, p. 158) are also beneficial. Internal treat- 
ment is especially useful when the disease is extensive or the patient is disinclined 
to undertake the troublesome and uncleanly local measures that are required. The 
arsenical mineral waters, as those of Roncegno and Levico, can also be used. 

No. 80. Diuretic Mixture. No. 81. Duhring's Arsenic Mixture. 

6: Liq- pot. arsenitis . . 1 part 

Vin. ferri . . . .24 parts 

3i in water t. d. after meals. 
b parts 

4 " ad. 

3ii t. d., well diluted. 

No. 82. Ichthyol-Arsenie Pills. No. 83. Pyrogallol Collodion. 

fy Ac. arsen gr. 1 R Pyrogallol .... 3 parts 

Ammon. sulph-ichthyolat. . . 3ii Bals. canaden. . . 2 " 

90 pills; 2 or 3 t. d. after eating. Collodion flexile . . . 32 " 

The local treatment is the more important, however, and it must be employed 
in the majority of cases. Any irritation or eczematous inflammation must be first 
gotten rid of by the use of Lassar's paste (No. 2, p. 43) or the zinc-oil (No. 65, 
p. 135). The scales must then be removed with hot water, a flesh-brush, and the green 
soap tincture (No. 5, p. 43). Of the local remedies to be employed, chrysarobin 
is the most reliable and efficacious. It is best used as a collodion (No. 51, p. 108), 
for its action can then be localized, and the indelible staining of the clothes that it 
occasions is much less marked than when it is used as an ointment. It excites a 
dermatitis if too freely applied to the unaffected skin, and an intense conjunctivitis 
if it happens to get into the eyes. It should therefore never be employed on the 
head and face. Under its use the scaling stops, the elevated masses subside, and 
there are finally left pale areas that represent the efflorescences of the disease, sur- 



R Kali acetat. . 


. 


. 


4 parts 


Spts. aether, nit. 


. 


. 


2 " 


Vin. colchic. 


• 


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1 part 


Syrp. aurant. . 


. 


. 


6 parts 


Aq. carui 


. 


. 


24 " ad. 




COPYRIGHT, BY E. B. TREAT 4 CO., N. Y. 



PHOTOGRAVJRE & COUOR CO., N. Y. 



PSORIASIS DIFFUSA 



PLATE XIX 



. 



CUTIS AND SUBCUT: 

DERMATITIS. 

- 

- 
- 

- 

ition. 

■ 

' ■ 







PHOTOGR/-VJRE * COL 



PSORIASIS DIFFUSA 



plat; 



INFLAMMATIONS. 159 

rounded by more or less deeply pigmented skin. The removal of this secondary 
pigmentation may be hastened by the local use of a citric-acid solution. 

Pyrogallol may be employed, like chrysarobin, as a salve or a varnish (No. 83, 
p. 158). It is not as efficacious as the latter, but it does not cause conjunctivitis, 
or stain the skin and linen or dye the hair so deeply. It must not, however, be 
used over too extensive a surface, since cases of poisoning have occurred. Tar, as 
the tincture (No. 10, p. 56) or as Wilkinson's ointment (No. 38, p. 82), is sometimes 
useful. The ointment of ammoniated mercury is slow, but moderately effective ; it 
is the preparation that should be used about the head and face. Anthrarobin in 
10-per-cent. ointment is harmless, but not nearly so effective as the others mentioned. 
Finally, any of these drugs can be used in the form of salve-mulls, plaster-mulls, 
collemplastra, or pencils in appropriate cases. 

2. DEEP-SEATED INFLAMMATIONS AFFECTING THE 
CUTIS AND SUBCUTIS. 

DERMATITIS. 

Synonym. — Inflammation of the skin. 

Definition. — An affection of the skin, characterized by the phenomena of inflam- 
mation, heat, redness, pain, and swelling, and ending in resolution, suppuration, or 
gangrene. 

Symptoms and Course. — Inflammation of the skin occurs as the essential phe- 
nomenon or as a secondary condition in many skin affections, some of which have 
been already considered. In certain forms, however, the inflammation is the primary 
process, and is directly caused by irritation of the skin from without or through the 
medium of the blood ; and these forms belong more specifically under this heading. 
The symptoms are the ordinary ones of inflammation of any organ, modified by the pe- 
culiarities of the skin and the predisposition of the individual. They can be produced 
artificially, as shown by Hebra. If a little croton-oil be rubbed into the skin for 
a short time, a transitory redness and swelling, the erythematous stage of dermatitis, 
are produced. This soon subsides and the process ends with a slight desquamation. 
If the action of the irritant is more prolonged we get successively the papular stage, 
with small elevated nodules appearing on the affected area, the vesicular and pustular 
stages, or the weeping stage, with a reddened skin secreting serum and pus. The 
inflammation may subside at any one of these stages, ending with desquamation, as 
the squamous stage ; or the process may terminate in chronic dermatitis or in gangrene 
and death of the affected skin. Finally, when the inflammation involves the hair- 
follicles or the sebaceous glands, a circumscribed inflammation, such as we see in 
furunculosis and folliculitis, is set up. Varieties of the affection have been clas- 
sified according to cause ; we shall consider dermatitis traumatica, dermatitis calorica, 
dermatitis venenata, and dermatitis medicamentosa. 



160 



ILLUSTRATED SKIN DISEASES. 



Dermatitis traumatica. Injuries to the skin cause the ordinary phenomena of 
inflammation, accompanied by itching, burning, or stinging. The process may not 
go beyond the hyperemic stage, but not infrequently suppuration with granulation 
and cicatricial repair, or even gangrene and sloughing, may result. Among its com- 
monest manifestations are the excoriations from scratching, which form an important 
part of the lesions in the various itchy diseases. Each such traumatism, with its sec- 
ondary inflammation, leaves a small deposit of blood-pigment in the skin, causing in 
the course of time that diffuse pigmentation which is seen as the result of long contin- 
uance of the pru- 
riginous maladies. 
Under this 
heading belongs 
the deep-seated 
or so-called paren- 
chymatous der- 
matitis of the 
lower extremities, 
that so frequently 
leads to chronic 
ulceration asasec- 
ondary phenom- 
enon. An injur}-, 
which may be 
very sliarht, a 
mere scratch or 
bruise, causes an 
inflammation in 
skin whose nutri- 
tion is already depressed by imperfect circulation due to the dilatation of the veins 
and lymphatics and consequent oedema. Under these circumstances the process 
shows no tendency to repair, molecular disintegration occurs in the center, and the 
chronic leg ulcer, the varicose ulcer, results. This may remain stationary for months 
or years, or it may slowly grow in size until it occupies the greater portion of the 
skin of the leg. One or several may be present, and they vary greatly in shape, 
size, and appearance. Their margins may be steep or sloping, thickened and cal- 
lous ; their bases may be covered with necrotic tissue, or with abundant, easily 
bleeding granulations, or they ma)' be red, dry, and shiny. The surrounding der- 
matitis is almost always extensive, and the amount of pain and tenderness varies 
greatly in different cases. This form of dermatitis is rare among the well-to-do, 
where the cleanliness and rest that are required for cure are usually promptly em- 
ployed ; but it is extremely common among the poorer classes, and is not only very 




Fig. 80. — Dermatitis traumatica (local action of arsenious acid). 
From photograph by the author. 




I 



DERMATITIS TRAUMATICA. 




TYPOGRAVURE. 




DERMATITIS HERPETIFORMIS. 

Pt'STULO-CRUSTACEOUS FORM. 



COPYRIGHT, 1902. BY E. B. TREAT i CO.. N. Y. 



DERMATITIS HERPETIFORMIS. 

VES1CULO HULLOUS FORM. 



PLATE LVI. 



INFLAMMATIONS. 



161 



chronic, but sometimes absolutely incurable, since they do not give the inflamed 
skin the care that it requires, and prolonged rest is an impossibility for them. 

Dermatitis calorica. Extremes of both heat and cold cause inflammation of the 
skin, but the former is by far the commonest causative agent. 

Dermatitis ambustionis or combustio, the inflammation of the skin caused by a 
burn or scald, is a frequently severe and a common affection. In its lightest form, 
the erythematous, the action of the irritant has either been momentary or of slight 




Fig. 8i. — Parenchymatous dermatitis. Fig. 82. — Parenchymatous dermatitis with ulceration. 

From photographs by the author. 

intensity. The skin is hyperemic, evenly pink or reddish, and there is moderate swell- 
ing and pain. The vascular dilatation soon diminishes, the redness fades, and the 
process ends in a few days with a slight desquamation. A severer form is the bullous 
one. The hyperemia is more marked, liquid and formed elements escape from the 
vessels, and semi-transparent globular bullae or blebs filled with a yellowish serum are 
formed. The papillary vessels of the inflamed area are dilated, and the connective- tissue 



162 



ILLUSTRATED SKIN DISEASES. 




Fig. 83. — Dermatitis ambustionis bullosa. 

From photograph by the author. 



fibers of the corium are swollen and infiltrated with cells. The serum may be 
absorbed and the blebs dry up into crusts under which the epidermis reforms, or 
they may be ruptured, and the cell-proliferation go on to suppuration and granu- 
lation, slowly terminating with more or less cicatrization. This is a much more 
painful and serious affection than is the erythematous form ; fever is usually present ; 
and when at all extensive, or when it occurs in debilitated subjects or at the extremes 
of life, it is liable to be fatal. Finally, in the escharotic form of combustio the irritant 

has been severe 
enough to cause 
death of the skin, 
and perhaps of 
the deeper parts. 
The integument is 
brownish or black- 
ish, or white when 
steam has been the 
escharotic agent. 
It may appear un- 
altered, but it is 
absolutely de- 

stroyed ; it is devoid of sensation and feels hard and dry to the touch. The dead 
mass must be cast off by the reactive inflammation of the adjacent living tissues 
with the formation of a line of demarcation and a suppurative process. The cavity 
left behind is filled up with new connective tissue, forming a scar without hair-papillaj 
or -glands. The subjective symptoms in this form of burn are marked and grave. 
Usually more than one variety or stage of dermatitis ambustionis is present in the 
same patient. 

Dermatitis congelationis or frost-bite also occurs in three degrees. Predisposition 
to its occurrence, especially in the lighter forms, seems to be necessary ; for healthy 
and vigorous individuals are not affected even after considerable exposure to cold. 
The mildest or erythematous form is the common chilblain or pernio. This occurs 
on the hands and feet, more rarely on the nose and ears. It appears as a bright- 
red or livid elevated area, and is accompanied by much itching and pain. A slug- 
gish inflammatory process is set up, which may end in resolution or go on to ulcera- 
tion. In the bullous form blebs appear exactly as in combustio. In the severest 
or escharotic form there are large bullae, possibly with hemorrhagic contents, or the 
skin is white, cold, and senseless. The part is gangrenous, and must be cast off by 
suppuration ; and phlebitis, septicemia, and death not infrequently occur. More often 
than in similar lesions caused by heat, however, there is a suspension rather than a 
cessation of vitality, and with appropriate treatment the part may return to the 
normal after an inflammation of greater or less severity. 







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to be 
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INFLAMMATIONS. 



16:5 



Dermatitis venenata. When due to the action of poisonous plants the inflam- 
mation may be erythematous, papular, vesicular, pustular, or bullous in form, ac- 
cording to the susceptibility of the skin and the amount of irritation caused by the 
poison. Some persons can handle the poisonous plants with impunity ; others suffer 
slightly when they 
come in contact with 
them ; while others, 
again, have the sever- 
est forms of the erup- 
tion when they come 
in their neighborhood. 
Individuals once af- 
fected are very liable 
to have recurrences at 
certain times, more 
often in the spring and 
the fall. Most usu- 
ally the eruption is 
markedly vesicular, 
with much swelling 
and erythematous 
redness. The hands 
and face are most fre- 
quently affected, and 
by direct transfer of the poison the genitals are usually involved. The malady lasts 
from one to several weeks. When due to the local action of drugs or to dyes in the 
clothing the inflammation may be very severe ; vesicles and bullae appear, and even 
gangrene may result. 

Dermatitis medicamentosa is an affection that closely simulates other cutaneous 
disorders, and is doubtless often mistaken for them. A large number of drugs, many 
of them in common use, may give rise to it. The eruption is frequently pustular, 
and the peculiar drug has in many cases been found in the pus. This seems to be 
largely due to an attempt on the part of the glandular structures of the skin to 
eliminate the foreign material. Such are the common iodine and bromine eruptions. 
Others are exanthematous and are accompanied by constitutional symptoms. Ar- 
senic and copaiba cause a papular eruption similar to erythema multiforme. Atropia, 
belladonna, and chloral cause a scarlatinoid rash. Opium, quinine, turpentine, and 
salicylic acid cause an erythematous eruption. 

Etiology. — Dermatitis traumatica is caused by contusions, wounds, pressure, as 
of tight clothing and bandages, excoriations with the finger-nails, lesions from tools 
used in the trades, and the non-toxic bites and stings of animals and insects. Der- 




FlG. 84. — Dermatitis venenata. 
From photograph by the author. 



164 ILLUSTRATED SKIN DISEASES. 

matitis calorica is due to the action of flame, hot or exploding vapor, hot solids or 
liquids, acid or alkaline caustics, lightning, electricity, and the sun's rays, or to cold 
air, snow and ice, etc. Dermatitis venenata is occasioned chiefly by the plants of 
the Rhus family, probably on account of the volatile toxicodendric acid that they 
contain. Two varieties are found on this continent, the Rhus venenata, poison-sumac 
or -dogwood, and the Rhus toxicodendron, the poison-ivy or -oak. The aniline dyes 
now so extensively used may cause dermatitis, as do also cantharides, savin, mezereon, 
arnica, mustard, croton-oil, mercurial salve, and other substances, when applied to 
the skin. Dermatitis medicamentosa may be caused by a large number of drugs, 
among which we may mention iodine, bromine, arsenic, atropia, chloral, copaiba, 
mercury, morphia, quinine, salicylic acid, and turpentine. 

Pathology. — The process is a simple inflammation of the skin of varying intensity, 
sometimes affecting the deeper parts and accompanied by certain secondary lesions, 
ulceration, etc. The ordinary phenomena and results of inflammation need no re- 
capitulation here. 

Diagnosis. — The history of the cause is usually obtainable ; the patient has been 
exposed to heat or cold or to injury, or he has been taking some one of the above- 
mentioned drugs. The marked vesicular eruption of poison-ivy, its location on the 
hands, face, and genitals, and the fact that the patient has been in some locality 
where the plant exists, will serve to prevent mistake. 

Prognosis. — This varies, of course, with the severity of the affection. It is good 
in the milder forms, but in the severer ones the possibility of incurability or the 
occurrence of gangrene, pyemia, and septicemia must not be lost sight of. In der- 
matitis calorica death may occur in the early stages from shock or later on from 
exhaustion and intercurrent disease. Severe burns, even if of slight extent, and 
burns that have not gone beyond the hyperemic stage, but involve one third of the 
entire integument, are of grave portent. In dermatitis venenata and medicamentosa 
the prognosis is always good. 

Treatment. — In dermatitis traumatica the first essential of treatment is to remove 
the cause. The inflammation usually then subsides spontaneously, but its disap- 
pearance may be hastened by the use of cold compresses or lead-water applications. 
Later on Lassar's paste (No. 2, p. 43) may be used, and the salicylic-sulphur paste 
(No. 79, P- 153) is useful where there is much desquamation. 

In parenchymatous dermatitis our first attention must be directed to the predis- 
posing and active causes of the inflammation. All sources of irritation must be 
avoided and the dilated veins must be supported with a carefully applied muslin 
bandage. Elastic stockings are expensive, since they soon wear out, and the ordi- 
nary rubber bandage macerates the skin and confines the secretions. Rest in bed 
and elevation of the limb are of the first importance ; unfortunately they cannot 
usually be employed in the patients that suffer from this affection. Of the many 
forms of treatment, I have found the most generally useful to be that with the 




i 



COPYRIGHT BY E. B. TREAT & CO. , N. Y. 



PHOTOGRAVURE 4 COLOR CC. , N. Y. 



DERMATITIS PARENCHYMATOSUS 









Bad c 

L veil 



No. 84. Carron-oil. 



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DERMATITIS : HYMATOSUS 



PLAT£ X 



INFLAMMATIONS. 16f) 

glyco-gelatin, recommended by Unna. The entire leg and foot are first thoroughly 
washed with hot water and soap, and then the whole surface is antiseptically cleansed 
with a i-per-cent. creolinora3-per-cent. carbolic- oraboracic-acid solution. After dry- 
ing, the glyco-gelatin (No. 4, p. 43), melted in a water bath, is evenly applied with a 
broad brush ; as it dries it is to be dabbed over with a fluff of cotton to increase its 
strength. A little iodoform is powdered over the sore, to be replaced by subnitrate 
of bismuth or dermatol if there is much secretion ; and if the granulations are abun- 
dant they must be cut down with the nitrate-of-silver stick. A layer of silk protec- 
tive and cotton is then applied over the limb from toe to knee; and after the 
glyco-gelatin has set, still another bandage. Before the gelatin is entirely hard a 
dry gauze bandage is evenly applied. Fenestras may be cut in the bandages to 
facilitate dressing of the ulceration if thought desirable. The dressing may remain 
on for from four to fourteen days, according to the amount of secretion. Besides 
this method of treatment, I can recommend the use of Lassar's paste (No. 2, p. 43) 
if the dermatitis is very intense. Bad cases may require ablation of the indurated 
edges of the ulcerations, skin-grafting, ligation of the dilated veins, etc. 

No. 84. Carron-oil. 

R Thymol 1 part 

Menthol 90 parts 

Aq. calcis 

01. lini 500 " 

No. 85. Ichthyol Collodion. No. 86. Duhring's Poisoti-ivy Lotion. 

Yji Amnion, sulph-ichthyolat. . 1 part ft Extract, grindelias rob. fid. . 1 part 

Collod. flexile . . .5 parts Aquae . . . . • 5° parts 

The treatment of burns consists, in the first place, in the use of stimulants as may 
be necessary, together with the administration of a full dose of opium or morphine. 
In burns of the erythematous and bullous degrees the blebs and vesicles should be 
punctured and the parts thickly dredged with starch or flour to protect them from 
the air and save the patient the excruciating pain that contact occasions. A good 
plan is the following: after the blebs are emptied the parts should be thoroughly 
cleansed with a 5-per-cent. salt or a i-per-cent. creolin or a boracic-acid solution; 
then carron-oil, possibly with the addition of thymol and menthol, should be used 
(No. 84, p. 165), or the lime-water-and-zinc paste (No. 78, p. 149). The iodoform 
treatment is applicable especially to severe cases, but is excellent for general use. 
After antiseptic cleansing the parts are covered with iodoform gauze, then with gutta- 
percha tissue, and lastly with cotton and a bandage. The cotton should be changed 
whenever the discharges soak through it; but the gauze may remain in situ for from 
eight to fourteen days. If the burn is extensive, or the patient is a child or aged, 
and iodoform poisoning is feared, the creolin gauze may be used instead. The sub- 



166 ILLUSTRATED SKIN DISEASES. 

nitrate of bismuth or dermatol, with gauze, cotton, and a bandage, is often used. 
In bad and extensive cases the permanent water bath has given good results. The 
patient is suspended in the bath by a stout sheet attached to its edges. Skin-grafting 
is often required for the extensive ulcerations left from burns. 

For chilblains stimulating applications and local frictions are useful. Hot com- 
presses may be applied frequently for short intervals of time. The 5-per-cent. col- 
lemplastrum of salicylic acid or a 10-per-cent. ichthyol collodion (No. 85, p. 165) 
is a good local application. In obstinate cases the epidermis should be removed by 
the application of a mixture of equal parts of dilute nitric acid and peppermint-water 
once or twice daily. Severer frost-bites require frictions in a cold room with ice- 
water or snow to prevent too great reaction. Sloughing and ulceration must be 
treated with antiseptic dressings. Cases of suspended animation from cold should 
not be regarded as dead until after artificial respiration has been persistently tried 
a long time, for cases have recovered when apparently dead for hours. 

In dermatitis venenata the parts should be protected from the air, and for this 
purpose alkaline lotions, bicarbonate of soda or borax, or a saturated solution of 
hyposulphite of soda, are useful. Dilute lead-water compresses are a favorite rem- 
edy. Duhring recommends Grindelia robusta very highly (No. 86, p. 165). The 
various soothing ointments, pastes, lotions, and oils can also be used (No. 26, p. 70, 
No. 29, p. 74, Nos. 65, 66, 68, 69, p. 135). 

Dermatitis medicamentosa requires only symptomatic treatment after its cause 
is removed. 

Cathode-ray dermatitis (see Plate XX.) has been seen in a number of cases. 
The lesions are those of an ordinary chronic or acute dermatitis, followed by marked 
exfoliation; but the deeper tissues, even to the periosteum of the bones, are some- 
times affected. 



ERYTHEMA NODOSUM. 

Synonyms. — Dermatitis hemorrhagica, dermatitis contusiformis, erytheme nonenx 
(Fr.). 

Definition. — An acute inflammatory disease, characterized by the formation of 
various-sized, rounded or oval, erythematous-looking nodes, situated most commonly 
on the lower extremities. 

Symptoms and Course. — The malady usually begins with marked general symp- 
toms — vomiting and fairly high fever, sometimes accompanied by delirium and 
pains in the joints. Then the eruption rapidly appears in the form of contusion-like 
nodes of considerable elevation, rounded or oval in shape. Their size varies from 
that of a nut to that of an egg ; they are warm to the touch, surrounded by an oedem- 
atous area, and painless, but tender to pressure. Their color is at first rosy red, 
changing to a duskier and more livid hue, and not removable by pressure. They 



INFLAMMATIONS. 167 

never coalesce or suppurate. In the course of eight or ten days they gradually 
disappear, going through the color-changes that are seen in blood-extravasations, 
and leaving a temporary dark-brown discoloration behind. Three or four nodes 
only are usually present, and their number rarely exceeds a dozen. Their regular 
seat is on the lower legs, more especially on their tibial aspects ; but they are 
sometimes seen on the arms, rump, face, and even on the mucosae. Though the 
individual lesions last only a few days, a succession of fresh ones often prolongs the 
disease for two or three weeks. Recurrences are rare. Fairly frequent complica- 
tions are purpura and erythema multiforme ; rarer ones are inflammations of the 
joints and serous membranes, and ulcerations of the skin or mucosae. The malady 
occurs in youth, and is most often seen in weak individuals. It is most frequent 
in the spring and autumn, and much commoner in the female than the male sex. 

Etiology. — The cause of this rather rare disease is still unknown. It is probably 
an infectious malady related in some way to acute articular rheumatism. 

Pathology. — This consists essentially of serous infiltration and blood-extravasa- 
tion of the various tissues of the skin down to the subcutis. 

Diagnosis. — Ordinary contusions may be mistaken for the nodes of erythema 
nodosum, but they never have the peculiar rosy color, are not usually multiple, are 
not rounded, there are no general symptoms, and there is the history of an injury. 
Syphilitic gummata may resemble them closely ; but the antecedent pains are much 
severer, they are slower in their course, are very rarely seen -in the young, and are 
almost always accompanied by other symptoms of lues, past or present. 

Prognosis. — This is generally good, though the complications above mentioned 
may cause death. 

Treatment. — This consists almost entirely in the symptomatic treatment of the 
initial fever and joint pains, with the administration of tonics. The disease will run 
its course without our aid. Lassar recommends the internal use of salicylic acid 
very strongly. Lead-water applications may be made to the nodes. 

ERYSIPELAS. 

Synonyms. — Rose, Rotlauf (Ger.), crysipcle (Fr.). 

Definition. — An acute infectious inflammation of the skin and mucosas, caused by 
the growth in them of the Streptococcus erysipelatis, and characterized by a diffuse 
'shiny redness with pain and swelling, and perhaps vesiculation, together with fever 
and general constitutional symptoms. 

Symptoms and Course. — The malady usually begins with a chill, followed by a 
marked rise of temperature and constitutional disturbance. About twenty-four hours 
later the temperature falls and the eruption appears, beginning as an irregular, red, 
glazed patch, with moderate itching and burning. The affected skin is hot, tense, 
cedematous, and infiltrated. Its margins are sharply limited, and the eruption spreads 



168 ILLUSTRATED SKIN DISEASES. 

at irregular intervals, marked by exacerbations of the fever. After extending for 
from three days to a week, retrogression begins, usually at one border ; the margin 
becomes indistinct, the redness and tension diminish, and the desquamation that 
marks the termination of the process begins. It may still, however, advance at the 
opposite margin ; and it may thus travel around the head more than once, or cover 
large areas of the body (erysipelas migrans, erysipelas ambulans). In bad cases the 
cedema and swelling are very great. If the face is affected the entire visage is 
deformed, swollen, and red, the eyes are closed, and the saliva dribbles from the 
tumefied lips. Vesiculation and crusting may occur, giving us the varieties known 
as erysipelas vesiculosum, bullosum, crustosum ; and subcutaneous abscesses and even 
gangrene may supervene. 

The general symptoms are usually severe. The remittent fever may reach 105 
to 107 . Temperature, pulse, and prostration are more dependent on the extent of 
skin inflamed than on the severity of the infection. The duration of mild cases is 
about a week ; but the migrating form may last much longer, and the patients once 
affected are extremely liable to recurrences of the disease. The malady may occur 
anywhere; but it is most frequent on the face, commencing about the nares, where 
eczema, fissures, etc., are so common. When erysipelas occurs on the scalp there 
is always danger of the occurrence of meningitis, as shown by the advent of head- 
ache, delirium, stupor, and vomiting ; and recovery is followed by falling of the hair. 
When erysipelas occurs on the scrotum gangrene is a frequent result. The malady 
is extremely infectious. 

As complications there may occur abscesses of the subcutis, gangrene of the af- 
fected part (erysipelas gangrenosum), suppurative inflammations of the joints and 
serosae, etc. Death may happen from exhaustion or pyemia. 

Etiology. — The Streptococcus crysipelatis, discovered by Fehleisen, is the cause 
of the disease ; but a lesion of the skin is required for it to enter the lymphatics. 
This may be a surgical or an accidental wound, an excoriation, a pus-crust, or an acne 
pustule, etc. In many cases the lesion is so insignificant that it cannot be found. 
The surgical and obstetrical form of the disease is becoming rarer every year, as 
antisepticism and cleanliness are more carefully observed. 

Pathology. — Erysipelas is a superficial or deep dermatitis of varying intensity, 
due to the growth of the cocci in the lymph-vessels and -spaces. The blood-vessels 
are dilated and distended with blood, and the cell-infiltration may extend down into 
the subcutis. Streptococci are heaped up in the lymph-vessels an inch or more 
beyond the red border of the disease on the skin. 

Diagnosis. — The peculiar shiny pinkish-red and swollen area, with the general 
symptoms, is quite characteristic. An erythema has no general symptoms, no pain, 
and no infiltration. Acute eczema also presents slight general symptoms, or none at 
all ; there are papules, vesicles, or weeping surfaces ; there is less infiltration, and there 
are no sharp borders. Chronic dermatitis is called by some authorities erysipelas 




COPYRIGHT, BY E. B. TREAT & CO., N. Y. 



PHOTOGRAVURE & COLOR CO., N. Y. 



ERYSIPELAS 



PLATE XXI. 






ans, or chronic erysipelas 
11 as its course, 



l 



Prognosis,— This depends on tl 
of time that it has been present, and the 
tions most to be feared are gangrene 
tons area will help us in deciding as 
;ted the :-ad. 

Treatment.— of anti- 

of erysipe careful steriliza; 

etc. — act with them, 

The basis of tent is a no. ! fluid 

alcohol i ith the amount of pr 

with antipyretics and baths. The tinctun 
20 to 30 drops every two or three hours, is 



;il cond 

i 



- 
- 

I 
I 

: 
;1 



No. 87. Ichlh 



■ 



R: Ichthyol 
Collod. 



5 parts 






. 






as clean . 

3 small amc. 
evacuated. An ice 
grene is feared it should nc: 
can employ, and it has displaced aim- 
: per-cent. solution, paste, colic- 
9, 90, p. 169). The most convenient is th 
tily. On the head the iclitlv 
oil, is efficacious. The ointments and lol 
siJe the patch toward the center, and in ... 
the apparent margins of the disease 
cent, pa Ive and tl 

•Its. We n 
ing strips of plaster 2 inches be 

■ 



ted; 

- 

used as a 

: 
i 










>£LAS 









INFLAMMATIONS. 



169 



perstans, or chronic erysipelas ; but the absence of the characteristic color and sharp 
outline, as well as its course, will serve to distinguish it. 

Prognosis. — This depends on the grade and extent of the erysipelas, the length 
of time that it has been present, and the patient's general condition. The complica- 
tions most to be feared are gangrene and meningitis. The border of the erysipela- 
tous area will help us in deciding as to its future course ; so long as it is sharp and 
elevated the disease will spread. 

Treatment. — The application of antisepsis to the smallest wound, the segregation 
of erysipelas patients, and the careful sterilization of everything — instruments, hands, 
etc. — that has come in contact with them, will prevent the spread of the disease. 
The basis of the general treatment is a nourishing fluid diet, with the free use of 
alcohol in accordance with the amount of prostration. The fever must be combated 
with antipyretics and baths. The tincture of the chloride of iron given in full doses, 
20 to 30 drops every two or three hours, is undoubtedly of service in many cases. 



No. 87. Ichthyol Collodion. 



ft Ichthyol 

Collod. flexile 



1 part 
5 parts 



No. 88. Ichthyol Ointment, No. 2. 



fy Ichthyol 
Aq. dest. 
Adip. lanse 



aa. p. e. 



No. 89. Ichthyol Lotion. 



ft Ichthyol . 
Ether 
Glycerin . 



1 part 
aa. 3 parts 



No. 90. Ichthyol Spray. 



ft Ichthyol 
Ether . 



1 part 
10 parts 



The local treatment consists, in the first place, in keeping the surface of the skin 
as clean and aseptic as possible by frequent washing with alcohol and ether contain- 
ing a small amount of the bichloride of mercury. Crusts must be removed and pus 
evacuated. An ice-bag may be applied to the head if that is affected; but if gan- 
grene is feared it should not be used. Ichthyol is the best local application that we 
can employ, and it has displaced almost all other remedies. It should be used as a 20- 
to 50-per-cent. solution, paste, collodion, or ethereal spray (No. 86, p. 165, Nos. 87, 
88, 89, 90, p. 169). The most convenient is the collodion, which should be applied sev- 
eral times daily. On the head the ichthyol spray, followed by inunctions of linseed- 
oil, is efficacious. The ointments and lotions must be rubbed in from the area out- 
side the patch toward the center, and in any case a surface at least 1 inch beyond 
the apparent margins of the disease must be treated. Resorcin in a 10- to 50-per- 
cent, paste or salve and the ^--per-cent. sublimate ointment (No. 43, p. 100) have also 
given good results. We may attempt to check the spread of the disease by apply- 
ing strips of plaster 2 inches beyond its advancing border and painting them over 
with flexible collodion ; and on the limbs rubber bands may be similarly employed. 



170 



ILLUSTRATED SKIN DISEASES. 



CHANCROID. 



Synonyms, — Soft chancre, non-infecting chancre, ulcus molle, weicher Schanker 
(Ger.), chancrelle (Fr.). 

Definition. — A specific, local, contagious, auto-inoculable, spreading ulceration 
of the skin. 

Symptoms and Course. — Chancroid has no period of incubation, the process be- 
ginning immediately after infection ; but it is usually two or three days later before 
the lesion is perceived. It first appears as a minute nodule or vesicle, which rapidly 
increases in size and becomes pustular. In exceptional cases, where the virus has 
been lodged in a crypt or follicle, it may be one or two weeks before the patient's 
attention is drawn to it. The pustule finally ruptures or dries up into a crust, re- 
vealing the characteristic chancroidal ulcer. This in its early stages is round, with 
sharp, undermined, punched-out edges, surrounded by a narrow, vivid-red, inflam- 
matory areola. No induration is present. The floor of the ulcer is irregular, bathed 
with pus, or covered with grayish fragments of necrotic tissue. As it grows to lentil- 
size suppuration becomes more profuse. A benign case goes on in this way for 
three to four weeks, until the ulcer has attained the size of a bean or a penny. When 
repair sets in the signs of inflammation diminish, the edges of the ulcer lose their 

sharpness, the areola disappears, and granulations 
spring up on the base of the sore. The seat of chan- 
croid is upon the genitals in almost all cases, most 
often upon the corona, glans, prepuce, frenum, me- 
atus, and labia minora ; in very rare instances it has 
been found on other portions of the body. It is 
always very sensitive, and pain is a marked feature 
in extensive cases. There is often more than one at 
the same time ; being auto-inoculable, parts that come 
in contact with the sore are frequently infected. The 
coalescence of adjacent lesions gives rise to ulcera- 
tions of irregular shape. 

Sometimes the chancroid does not follow this 
comparatively benign course, but becomes phage- 
denic, assuming a diphtheritic or gangrenous appear- 
ance. It advances rapidly and leads to deep and extensive destruction of tissue. In 
other cases it heals at one margin while advancing at the other, forming the serpigi- 
nous variety of the disease. The lymphatic glands leading from the affected area 
are always swollen and tender, and a tumefaction of the inguinal lymphatic glands, 
the bubo, is a regular accompaniment of the disease. This latter frequently goes 
on to suppuration, the abscess bursts or is opened, and a large chancroidal ulcer, 




Fig. 85. — Chancroid. 

From cast from life by the author. 



INFLAMMATIONS. 



171 



with ragged, sloughing base and undermined edges, is left behind. The ulcerative 
process is frequently very chronic and may last for months ; pocketing and sinus for- 
mation frequently occur ; and I have known the destruction in one case to extend on to 
the abdomen and cause death by opening the peritoneal cavity. In any case the mark 
of the chancroidal process is permanent. The papillary layer of the affected skin is 
destroyed, and scars, contractures, and deformities result. Destruction of the frenum, 
phimosis, and paraphimosis are liable to occur, as are also erysipelas and gangrene. 
The possible presence of syphilis 
as a complication, the patient hav- 
ing contracted that disease at the 
same time as the chancroid, must 
never be lost sight of. 

Etiology. — We can say nothing 
positive in this regard as yet, save 
that it is undoubtedly due to an 
organic body of some kind. Micro- 
organisms have been described by 
Ducrey and by Unna, but their re- 
lationship to the disease has not yet 
been proved. 

Pathology. — The process is an 
acute inflammation of the skin, with 
rapid molecular destruction of the 
tissues. The corium under and 
around the ulcer is infiltrated with 
small cells, and the papillary layer 
is ultimately destroyed. The open 
mouths of the lymphatic vessels 
can be found in the bases of the 
ulcers. 

Diagnosis. — The short incuba- 
tion, the beginning with a pustule, 
the undermined irregular edges and 
dirty necrotic base, the inflammatory areola, the multiplicity, and the auto-inocula- 
bility are sufficiently characteristic of chancroid. It requires to be carefully differ- 
entiated, however, from two other conditions that are common on the genitals, 
chancre and herpes. Hard chancre has an incubation of from ten to fifty days ; it 
begins as a papule, and is usually single ; it has an extensive induration which re- 
mains long after the lesion has passed away ; its edges are not undermined ; it secretes 
a small amount of seropurulent fluid ; and the swelling of the lymphatic glands is 
moderate, very hard, and painless. The absence of these points does not enable us, 




-Chancroidal ulceration of labia. 
From photograph by the author. 



172 



ILLUSTRATED SKIN DISEASES. 



however, to exclude chancre ; we must wait for that until the longest possible period 
of primary incubation of syphilis has passed, since double infection may have oc- 
curred, and induration may appear around the chancroidal ulcer or in its scar later 
on. In herpes progenitalis we have grouped vesicles, not pustules ; there is no tend- 
ency to spreading and no bubo ; the affection is very superficial and not followed by 
scarring; there is usually a history of previous attacks; and the lesion has no neces- 
sary connection with coitus. 

Prognosis. — In uncomplicated cases 
this is very good, but no opinion as to 
the presence of syphilis can be given un- 
til two and a half months later. The 
occurrence of bubo has no relation to 
the size or extent of the chancroid. In 
bad serpiginous and phagedenic cases 
death sometimes occurs by sepsis. 

Treatment. — Scrupulous cleanliness 
and the prevention of contact of the sore 
with other portions of the integument 
by means of pledgets of cotton and 
bandages are essential. Our object in 
treatment is to transform the virulent 
into a simple sore. After thorough 
cleansing of the base of the ulcer pure 
carbolic acid can be freely applied, care 
being taken that all the recesses and 
crevices of the ulceration be reached. 
If that is not effective, nitric acid or 
the acid nitrate of mercury can be used 
in the same way. Hyde prefers the 
galvanocautery. In all these cases co- 
caine should be used to mitigate the 
pain. A simple iodoform or other anti- 
septic dressing suffices for the after 
treatment. In phagedenic cases the 
continuous hot-water bath at a tem- 
perature of 98 has given the best re- 
sults. 




Fig. 87. —Ecthyma. 

From photograph by the author. 



Ecthyma, like impetigo, is no longer regarded as a distinct disease, but rather as 
a form of cutaneous inflammation that occurs in various affections. It appears as a 
round or oval, deep-seated, yellow pustule, bean- to Albert-size, and situated on 
a markedly inflammatory base. The contents dry up into a thick, rough, adherent 



INFLAMMATIONS. 



173 



crust composed of pus and blood. Under the crust we find a deep ulceration, with 
a grayish or reddish base covered with indolent granulations. The papillae are fre- 
quently destroyed, and scarring results. The cause of the inflammation is always 
infection with pus-cocci, most commonly transplanted into the skin with the finger- 
nails. Hence ecthyma occurs in the various itchy diseases, more especially in 
phtheiriasis, scabies, and urticaria, and is most commonly seen in poor and uncleanly 
individuals. Other diseases, as variola and chancroid, occasionally exhibit deep- 
seated pustules of ecthymatous form, probably on account of infection with pus-cocci 
as well as with the specific organisms of the main disease. 



FURUNCULOSIS. 

Synonyms. — Boil, furuncle, Furunkel, Blutschwar (Ger.), furoncle (Fr.). 

Definition. — An acute circumscribed phlegmonous inflammation of the skin 
around a cutaneous gland, 
ending in necrosis of the cen- 
tral area, and caused by the 
presence of pus-organisms. 

Symptoms and Course. — 
A small punctate spot first 
appears on the skin, usually 
pierced in its center by a 
lanugo hair. This rapidly in- 
creases in size, and in a day 
or two becomes a circum- 
scribed, elevated, hard, pain- 
ful infiltration \ to I inch in 
diameter. It becomes acu- 
minate, and in twenty-four to 
forty-eight hours a minute 
yellow point at the apex 
shows the presence of pus. 
Suppuration goes on for a 
week or longer, and then the 
furuncle breaks, and a day or 
two later the central core is 
extruded. The crateriform 
ulceration heals rapidly, leav- 
ing a temporary pigmentation 
and small permanent scar be- 
hind. Furuncles may appear 

. Fig. 88. — Furunculosis. 

anywhere on the body where From photograph by the autho r. 




174 ILLUSTRATED SKIN DISEASES. 

there are sebaceous follicles and hair-sacs ; but they are commonest on the neck, 
buttocks, axillae, and in the external auditory passages. There may be one or many ; 
but, since auto-inoculation usually occurs, the patients generally suffer from a suc- 
cession of single boils or of crops of them, which may prolong the malady for months, 
forming the condition known as furunculosis. The amount of pain depends on the 
seat of the lesion and the tension that it is subjected to. It is frequently consider- 
able in situations like the perineum and the external auditory meatus. Fever and 
constitutional symptoms often accompany the outbreaks. 

Etiology. — Furunculosis is caused by the growth in and around the follicles of the 
skin of the pyogenic staphylococci. It is usually inoculated in the integument 
with the finger-nails. Certain constitutional conditions, and cachexias, diabetes, 
uremia, and the gastro-intestinal diseases of children, seem to predispose the skin 
to its occurrence. So also does the external use of tar, chrysarobin, and pyrogallol. 
It is not surprising that it is of common occurrence in many of the itchy skin diseases, 
more especially in eczema, scabies, and prurigo. 

Pathology. — The circumscribed phlegmonous inflammation occurs in and around 
a follicle, most often a hair-sac, and involves all the tissues of the skin. The inten- 
sity of the inflammation is such that necrosis of the central inflamed area takes place, 
and the dead tissue is cast off as the " plug " in the reactive inflammation that ensues. 

Diag-nosis. — The hard, circumscribed, painful, acuminate infiltration with yellow 
apex is characteristic. An ecthymatous pustule has no core, is not so deep, and has 
a larger inflamed areola round it. Carbuncle is larger, often several inches in di- 
ameter, and flatter ; it has two or more points of suppuration, and it is almost always 
single. 

Prognosis. — This is almost always good. On the face, however, the dangers of 
phlebitis and thrombosis of the cerebral veins must not be lost sight of. When it 
occurs in the course of grave constitutional disease, like diabetes, furunculosis may 
be a more serious affection, and hasten a fatal termination by the pain, exhaustion, 
and loss of sleep that it occasions. 

No. 91. Menthol-oil. 

$ Menthol . i part 

Ol. olivae . ... 4 parts 

Treatment. — The cause, if possible, must be found and removed. The urine 
should be examined for sugar, and any underlying disease should be appropriately 
treated. Tonics are always useful in long-continued cases. Prophylaxis consists 
in cleanliness ; frequent bathing, more especially with enough of the permanganate 
of potash added to the bath to give the water a claret color, is required. Internal 
remedies supposed to have a specific action on the suppurative process, such as the 
sulphide of calcium, and local procedures designed to abort the boils, have been 



INFLAMMATIONS. 



175 



absolutely useless in my hands. The entire affected area should be thoroughly 
cleansed with sublimate, carbolic- or boric-acid solutions,, and then a piece of the 
mercury-carbolic plaster-mull applied to the boil. This should be done at least 
three times daily. Incision, which should be free, and followed by a thorough curet- 
ting, is frequently required. Wolff recommends the thorough rubbing in of iodoform 
or aristol and an occlusive dressing after it. Boils should never be squeezed to ex- 
press pus or necrotic tissue. In furuncle of the external auditory meatus the passage 
should be cleansed as well as possible with a warm 3-per-cent. boric-acid solution, 
followed by warmed menthol-oil on cotton (No. 90, p. 1 74). 



CARBUNCULUS. 



Synonyms* — Anthrax, Brandschwdr (Ger.). 

Definition. — An acute circumscribed phlegmonous inflammation of the skin and 
subcutis, ending in gangrene, and caused by the presence in the skin of pus-organ- 
isms. The term " anthrax," though commonly 
used for this affection, is incorrect ; anthrax is a 
specific disease of animals and men caused by the 
Bacillus anthracis; its initial lesion is known as 
the malignant pustule, and it has no connection 
with the disease under consideration. 

Symptoms and Course. — Carbuncle begins as 
a circumscribed, deep-seated, hard, painful, red, 
and erysipelatous-looking infiltration, of consid- 
erable extent from the first. It increases in size 
for about two weeks, and finally forms a firm, 
brawny, dusky-red or violaceous swelling. Points 
of suppuration appear in the center of the mass, 
from which a thin sanious pus trickles out; and 
from each opening a core or plug of necrotic tis- 
sue is finally expelled. The tumor softens in 
the center, the ridges of dusky skin between 
the numerous openings break down, and, after 
the sloughing is complete, the dead parts are 
cast off and a deep granulating ulceration is left 

behind. The size of the carbuncle varies from that of a child's fist to that of a din- 
ner-plate ; and by peripheral progression while sloughing and suppuration are going 
on in the center, extensive lesions, covering perhaps half the back, may be formed. 
In bad cases not only is there complete and extensive necrosis of the cutis and sub- 
cutaneous tissue, but even the muscles and the periosteum of the bones may be in- 




FlG. 89. — Carbuncle. 
Case of Dr. A. H. Ohmann-Dumesnil. 



176 ILLUSTRATED SKIN DISEASES. 

volved. An extensive stellate and often pigmented cicatrix is left behind when the 
ulceration heals. 

The carbuncle is usually single, and its seat is most often upon the back, neck, 
cheeks, and lips. The constitutional symptoms vary with the extent of the inflam- 
mation and the general condition of the patient. Fever, gastro- intestinal disturb- 
ance, and general malaise are present in all cases, and in bad ones septic infection 
and pyemia may set in. Local extension may cause pleurisy, peritonitis, and cere- 
bral or spinal meningitis. The entire process lasts from two to six weeks. 

Etiology. — Infection with pus-cocci is the cause of carbuncle. This probably 
occurs simultaneously in a number of neighboring follicles. Diabetes, uremia, and 
a number of other constitutional conditions predispose to the occurrence of the 
disease. 

Pathology. — The process is analogous to that in furuncle ; the staphylococci 
excite a perifollicular inflammation which is intense enough to cause connective- 
tissue necrosis. The dead parts are then cast off by reactive inflammation. 

Diagnosis. — From a furuncle a carbuncle may be distinguished by its greater 
size, its flatness, its multiple suppurative centers, and the fact that it is usually single. 
Malignant pustule is not so inflamed and brawny, nor so painful, and the character- 
istic organisms can be found in the fluids of the charbonous part. 

Prognosis. — With the smaller tumors the prognosis is good ; but in extensive 
cases, and especially in those occurring in the course of grave constitutional disease, 
it is bad. It should be guarded in any case ; septicemia and pyemia may always 
occur ; local spreading may erode the vessels and lead to a fatal hemorrhage, and 
the patient may die of exhaustion from the long-continued suppurative process. 

Treatment. — Any underlying disease, diabetes or Bright's, must be appropriately 
treated. Tonics, a generous diet, alcoholics in moderation, and all other means to 
sustain the organism must be employed. In the beginning the mercury-carbolic 
plaster-mull is useful. Free and deep incision followed by a thorough curetting is 
undoubtedly of benefit in some cases, but complete surgical extirpation of the tumor 
is better. The ethyl-chloride spray may be employed to anesthetize the parts 
before operation, and the wound should be dressed with iodoform. In moderately 
extensive cases the old-fashioned method of poulticing to promote the separation of 
the sloughs is perhaps as good as any. • , 

THE GRANULOMATA. 

The granulomata are inflammatory processes somewhat similar to the new growths. 
They are all caused by the invasion of the integument by a microorganism, though 
in some cases no decision has yet been reached as to its exact nature. They are: 
(i) tuberculosis; (2) syphilis; (3) lepra; (4) mycosis fungoides; (5) lupus erythe- 
matosus; (6) rhinoscleroma; (7) actinomycosis. 




COPYRIGHT BY E. B. TREAT & CO., N. 



PHOTOGRAVURE 4 COLOR CO., N. Y. 



LUPUS VULGARIS 

PLATE XXV 









- 
cal factor and even th 

y are small c 
They are, however, clin 
(2) lupus vulgari 

, TUBERCULOSIS CUTIS. 

. Tn 

in pa >und 

themuco penis, 

these areas. T 
\ to 1 inch Jrec l 

i 
occas 

internal 1 
diffic 

. 






■ 

The 

- 



VULGARIS. 

Synonyms.- 

(Ger.). 
Definition. — A chroi 

with on 

Symptoms and Course* — Thi 

I 

1 

■ 

1 



INFLAMMATIONS. 177 

Several affections, formerly considered distinct diseases, have been found to be 
caused by the tubercle bacillus and are really tuberculoses of the skin. The etiologi- 
cal factor and even the elementary pathological lesion are the same in all cases. 
They are small cell-accumulations containing varying numbers of the specific bacillus. 
They are, however, clinically distinct. We shall consider: (i) tuberculosis cutis; 
(2) lupus vulgaris; (3) scrofuloderma; (4) tuberculosis cutis verrucosa. 

TUBERCULOSIS CUTIS. 

True tuberculosis cutis is very rare, and occurs almost always from auto-infection 
in patients suffering from tuberculosis of other organs. It is seen in the skin around 
the mucous orifices of the body, about the mouth, nose, anus, and on the glans penis, 
infection being directly transmitted in the saliva and the discharges that come in con- 
tact with these areas. It appears as one or more small, shallow, painless ulcerations, 
£ to I inch in diameter, with flat borders, sloping margins, and with bases covered 
with reddish granulations, in which minute yellowish-white miliary nodules can 
occasionally be seen. In exceptional instances it is primary, and no tuberculosis of 
the internal organs has been found. The diagnosis is usually made, without much 
difficulty, from the presence of internal tuberculosis and the finding of tubercle-bacilli 
in the secretions. An ulcerating syphilide, the only affection with which it is liable 
to be confounded, has infiltrated hard borders and a dirty base, and other symptoms 
of lues are present. The prognosis depends on that of the internal lesions. The 
best local treatment is the thorough use of the sharp curette or the Paquelin cau- 
tery, followed by an iodoform dressing. Diluted acetic or chromic acid may also be 
employed. 

LUPUS VULGARIS. 

Synonyms. — Lupus vulgaire, dartre rongeantc, scrofulide tuberculeuse (Fr.), 
fressende Flechte (Ger.). 

Definition. — A chronic local tuberculosis of the skin and adjoining mucosae, charac- 
terized by the appearance of various-sized, reddish-brown, soft, deep-seated nodules, 
with subsequent ulceration or interstitial absorption, and ending in cicatrization. 

Symptoms and Course. — The lesion of lupus, the primary efflorescence, is char- 
acteristic ; it is present to some extent in all forms of the disease, and the diagnosis 
of the malady rests finally upon its discovery. It is a pinhead- to small pea-sized 
nodule, yellowish or brownish red in color, and seated so deep in the corium that 
usually it does not project from the surface and cannot be felt. It is composed of a 
granulation tissue so soft that, when a pin is introduced into it, its point can readily 
be moved about in all directions. In many cases these nodules can be seen only 
with difficulty ; but pressure on the part with a glass pleximeter or microscopic slide 



178 



ILLUSTRATED SKIN DISEASES. 







1 




V""* Mi- ■ 


vmi 






?m 



Fig. 90. — Lupus hypertrophicus. 

After Lesser. 



(diascopy) expresses the blood from the surrounding parts, so that the lesion appears 
as a brown discoloration when seen through the transparent medium. 

The lupoid process is varied in its manifestations, but its different names do not 
designate distinct varieties. They are all formed by groupings of numbers of the 

primary lesions, together with the results and sequelae 
that ensue. It begins always as a red spot, in which 
the primary nodule can be appreciated only with the 
aid of pressure. The spot is usually small in area 
at first, and in this stage the disease is known as 
lupus maculosus. The nodule increases in size very 
slowly, and it may be months before it becomes per- 
ceptible to the touch. When it attains the size of a 
small pea retrogressive changes, consisting of fatty 
degeneration of the new cells, with interstitial ab- 
sorption, begin ; there is rather abundant scaling 
(lupus exfoliativus), and the process ends with scar 
formation. In other cases disintegration and ulcera- 
tion occur (lupus exedens or exulcerans). The lu- 
poid ulcerations are rounded, shallow excavations, 
with soft red borders, and pink, granulation-covered, 
easily bleeding bases. Like all the other stages of 
the disease, they are exceedingly chronic, lasting for months and years ; there is mod- 
erate suppuration and crusting, but no pain. Not infrequently there occur papillary 
outgrowths from the bases of the ulcers — lupus papillaris or hypertrophicus ; and 
larger connective-tissue masses in with the scar give us lupus verrucosus. 

Groups of papules aggregated together give us the form known as lupus tuber- 
culosus. If the lesions are isolated, we have lupus discretus ; if they are spread over 
a large area of the body, lupus disseminatus. Very frequently they spread peri- 
pherically, the older ones breaking down and being absorbed while new nodules are 
appearing at the periphery of the patch ; this variety is known as lupus serpiginosus. 
Of especial importance, and pathognomonic, is the appearance of new nodules in the 
scars that have resulted from the lupoid process. 

The lupoid nodules are deep-seated in the corium, and the subcutaneous tissue 
is frequently affected. When the skin lies over cartilage, as on the nose and ears, 
the perichondrium and the cartilage itself are often involved in the destructive pro- 
cess, but the bones are rarely attacked. The disease may affect any part of the body, 
but is most frequent upon the face, and especially upon the nose ; and here the process 
is most commonly of the tubercular variety. In bad cases of long standing it leads 
to terrible deformity : the cartilages of the ear and the alae nasi may be destroyed ; 
the anterior nares may be entirely closed up with cicatricial tissue; ectropion and 
other deformities may result from cicatricial contraction ; a circle of ulcerations may 





TYPOGRAVURE. 



COPYRIGHT, 1902, BY E. B. TREAT 4 CO.. N. Y. 



SCROFULODERMA. 



LUPUS HYPERTROPHICUS. 



PLATE Llll. 



INFLAMMATIONS. 



179 



surround the mouth ; while the rest of the visage is covered with cicatricial tissue. 
On the trunk the malady is usually extensive, very chronic, and of the serpiginous 
variety. On the legs the lesions are commonly of the warty, hypertrophic form. 
The malady is very rare on the scalp and genitals. 

The mucosae are usually affected secondarily, from extension of the disease from 
the skin around one of the mucous orifices ; but it may occur primarily on the gums, 
on the tongue, inside the nose, on the con- 
junctivae, and even in the larynx. Here the 
characteristic lesion is rarely seen ; instead 
of it we have shallow ulcerations or patches 
of papillary excrescences. In the larynx 
the cartilages, and more especially the epi- 
glottis, are frequently destroyed. 

Lupus begins in childhood, and may last 
for fifteen or twenty years. As a rule, even 
in bad cases, the general health is not in- 
terfered with. It is seldom associated with 
internal tuberculosis, even when the lupoid 
ulcerations have invaded the buccal cavity. 
In the circumscribed cases but little scar- 
ring, and that superficial, results. 

Etiology. — The cause of the disease is 
the presence of the tubercle-bacillus in the 
skin. This was first proved to be the case 
by Koch, and it has been confirmed by the 
experimental production of both local and 
general tuberculosis with the material de- 
rived from the lupus nodule. It seems probable that in a good many cases the 
disease is caused by direct inoculation, infection being gotten from kissing persons 
affected with tuberculosis of the lungs. For some unknown reason it is much 
commoner in females than in males. It is very rare before the third year of life, 
though cases have been reported in infants; and it seldom originates after puberty. 

Pathology. — The lupus nodule is a granuloma, due to the irritation caused by 
the presence of the tubercle-bacillus and its products. It is a true miliary tubercle, 
a round-cell collection appearing first along the vessels of the cutis. The cells always 
undergo necrobiosis and fatty and cheesy degeneration; organization never occurs. 
The tubercle-bacilli are few in number and hard to find ; they are most readily 
demonstrated in the new nodules on the margins of the lupoid patch. 

Diagnosis. — Lupus usually presents a characteristic and readily recognizable 
picture, but in some cases the diagnosis is a matter of difficulty. It begins in youth ; 
has a very chronic course ; shows the characteristic nodules either to the unaided 




Fig. 91. — Lupus vulgaris 
After Lesser. 



180 ILLUSTRATED SKIN DISEASES. 

eye or by means oL diascopy ; has painless ulcerations, with soft borders and exu- 
berant granulations ; is situated most frequently upon the face, more especially on 
the nose; destroys the cartilages, but does not affect the bones; and shows a con- 
tinuous production of fresh lesions, sometimes in the scars of the formerly dis- 
eased area. It most frequently requires to be differentiated from syphilis of the 
ulcerative and gummatous forms, lupus erythematosus, tuberculosis cutis, and cancer. 
Syphilis is comparatively rapid in its development, covering in weeks an area that 
lupus takes years to occupy ; its papules are hard, projecting, and copper-colored ; 
its ulcers have elevated and indurated edges, sunken dirty bases, and are painful; 
its scars are at first pigmented; the bones are frequently affected; it usually begins 
after puberty ; and other signs of syphilis are generally present. Lupus erythema- 
tosus has a bright-red border, a slight central atrophy, no ulceration, and the char- 
acteristic seborrheal scales with projecting plugs on their under surfaces. The ulcers 
of tuberculosis cutis are covered with weak, flabby granulations, occasionally -show 
visible miliary tubercles, and generally coexist with tuberculosis of the internal 
organs. Carcinomatous ulceration should not be mistaken for lupus ; its extreme 
hardness, its elevated and indurated edges, its pain, the involvement of the lymphatic 
glands, together with its almost invariable occurrence in old age, being characteristic. 
It does not seem likely that eczema, with its secretion, absence of ulceration and 
scarring, or rosacea, with its dilated vessels, comedones, and non- destruction of 
tissue, can be confounded with the disease. 

Prognosis. — Lupus does not endanger life ; but its intractability, and the deformi- 
ties caused by the destruction of large areas of the skin, more especially upon the 
face, together with those caused by the inevitable contracture of the scars, render 
the prognosis bad. We are entirely unable to prevent the fresh appearance of nod- 
ules. Besides this, every case harbors the tubercle-bacillus, and the possibility of 
the infection of important organs or the system at large must not be lost sight of. 

Treatment. — General treatment is of little use, since most of these patients enjoy 
good health. Creosote and cod-liver oil may be given, as for internal tuberculosis. 
Good effects, but no cures, have been gotten from the use of thiosinamine, recom- 
mended by H. von Hebra, a few minims of a 15-per-cent. alcoholic solution of the 
drug being injected between the shoulder-blades daily. 

Local treatment consists in endeavoring to procure the absorption of the new 
tissue or in destroying and removing it. The first may be tried in the localized and 
non-ulcerative forms of the disease, the parts being covered with the salicylic-acid- 
creosote plaster-mull, or the mercurial plaster, which may be kept in place by means 
of glyco-gelatin (No. 4, p. 43), and should be changed daily. Good results, with 
comparatively little scarring, are sometimes obtained in this way. But in most cases i 
especially in the ulcerative and hypertrophic forms of the disease, it is best to pro- 
ceed at once to the destruction of the granulomata. The most radical method is 
complete excision, followed by any plastic operation that may be necessary; it is 




COPYRIGHT, BY E. B. TREAT & CO. , N. Y. 



PHOTOGRAVURE 4 COLOR CO. , N. Y. 



LUPUS VULGARIS 



PLATE XXV! 



o on] 

iould be very thoroi ieed 

no fear of destr r uon 

10-per-cent the 

aiocaute ly method of de 

..^tion of hypertn | 
hap; rice. Scarificatk 

■ 

ita. 
■ 

a of 
caus* ir ply 

pointed, may be dug into ea 
still 

,ults; it should be rubb the part b, or 

be used -..lied on 

>:y minu 
Ten-per-cent. p> 
into a sc 

re to 

I 

10 

. 






Which e 

i ■ 

SCROFULODF 

c I 

- 



INFLAMMATIONS. 181 

applicable, however, to only a few cases. Much more generally useful is curetting, 
which should be very thoroughly done, preferably under anaesthesia. There need 
be no fear of destroying the much more resistant healthy tissue. The application 
of a io-per-cent. sublimate spirit should follow the operation. The Paquelin or the 
galvanocautery is a ready method of destroying the nodules, but it is very liable 
to be followed by the formation of hypertrophic scar tissue or false keloid, as has 
happened in my own experience. Scarification, followed by the application of 
mercurial plaster, is less efficacious, but is not open to the same objection. 

Chemical substances are most frequently resorted to to destroy the granulomata. 
They should be used on the end of a wooden toothpick wrapped with a little cotton, 
which must be dug into each lupus nodule. Pure carbolic acid, or a solution of 
caustic potash, I to 2 of water, may be used. The nitrate-of-silver stick, sharply 
pointed, may be dug into each visible nodule ; this is painful, but effective, and is 
still the favorite method with many dermatologists. Lactic acid has given very 
good results; it should be rubbed vigorously into the part by means of a swab, or 
it may be used in ointment form (No. 92, p. 181), applied on lint to the part for 
twenty minutes every other day. It acts better if scarification precedes its use. 
Ten-per-cent. pyrogallol ointment (No. 93, p. 181) will transform the lupoid tissue 
into a soft, dark mass, and destroy it. Very lately the use of cinnamonic acid has 
been highly recommended. One or two drops of the solution (No. 94, p. 181) are to 
be injected with the hypodermic syringe into each lupus nodule, especially at the 
margins of the patch ; about ten injections can be given at a sitting. 

No. 92. Lactic-acid Ointment. No. 93. Pyrogallol Ointment, No. 2. 

FJ: Ac. lact. .... 1 part R Pyrogallol .... 3 parts 

Adip. lanae . ... 9 parts Adip. lanas . . . 10 " 

Petrolati . . . . 20 " 

No. 94. Cinnamonic-acid Injection. 

R Ac. cinnamyl 

Cocaine mur. . . aa. 1 part 

Spirit, vini . . . 18 parts 

Whichever method is selected, cocaine in io-per-cent. solution externally or 
i-per-cent. subcutaneously, or the ethyl-chloride spray, should be employed when 
no general anesthetic is used. 

SCROFULODERMA. 

Synonyms. — Lichen scrofulosorum, lichen lividus, acne cachecticorum, gommes 
scrofulenscs (Fr.). 

All the so-called " scrofulous " affections are now regarded as either tubercular 



182 ILLUSTRATED SKIN DISEASES. 

or syphilitic in nature. The scrofulodermata are local tuberculoses of the skin, 
closely related to true tuberculosis of that organ and to lupus vulgaris. At least 
three clinically distinct forms are to be described under this heading, according 
to whether the tuberculous nodule remains a small, circumscribed, non-ulcerating, 
and non-degenerating tumor, or whether it develops into larger infiltrations that 
end in degenerative and suppurative processes. 

i. Scrofuloderma papulosum, lichen scrofulosorum, or lichen lividus. This form 
of dermal tuberculosis is rare in this country; Hyde says it does not occur; yet I 
described and figured a case in the " Journal of Cutaneous and Venereal Diseases " 
as long-ago as May, 1886. It appears as pinhead- to lentil-sized, flattish, slightly 
elevated, pale or livid red papules, moderately resistant, and mostly capped with a 
minute scale. They are arranged in groups of varying size, more rarely in rings, 
and there may be a single group or a number of them scattered over the body. 
Each single papule corresponds to a hair-follicle, and many of them are pierced by 
a minute hair; the skin between them is normal. The seat of the groups is most 
often upon the trunk, more especially on the chest, abdomen, and back ; only in old 
and extensive cases are the limbs invaded. The malady occurs in young individuals 
only ; it is very chronic, the individual lesions lasting a long time, and successive crops 
may prolong the disease for years. The papules disappear by absorption, leaving 
no trace behind, or they may go on to develop into the pustular form of the disease. 
They cause no subjective symptoms, and are sometimes discovered only accidentally. 

2. Scrofuloderma pustulosum or acne cachecticorum is similar in its location 
and general symptomatology to the papular form, and probably follows it in most 
cases. The pustules rupture or dry up into crusts, giving rise to very sluggish, 
ecthyma-like ulcerations. 

3. Scrofuloderma ulcerosum, scrofuloderma tubero-ulcerosum, or tubercular 
gummata. Here the tubercular mass forms a hard, painless, movable, nodular 
infiltration of varying size, deep-seated in the skin, which slowly turns into a cold 
abscess. The process may stop at any stage and the mass undergo fatty and cheesy 
degeneration, and even calcification; but it usually goes on to softening. The skin 
gets thin, red, and adherent, and there appear one or more perforations, through 
which a thin, purulent, detritus-containing material trickles out. Finally the integu- 
ment gives way, and a painless ulcer, with lax, thin, undermined edges, an uneven 
base covered with pale, flabby, yellow granulations, and running a very sluggish 
course, is left behind. Crusts may be formed by desiccation of the secretion of the 
ulcer, and under these the destruction may extend far into the underlying tissues. 
Wolff records a case in which the frontal bone was perforated so that the pulsating 
dura could be seen at the bottom of the ulcer. One or several of these tumors or 
ulcers may be present. They finally heal with a flat, soft scar, which is depressed 
where bone or lymphatic- gland tissue has been destroyed. This is by far the com- 
monest form of scrofuloderma ; it occurs usually in the young, and may last for years. 



INFLAMMATIONS. 183 

Etiology. — The cause of these varying phenomena of cutaneous disease is the 
presence of the tubercle-bacillus in the skin. We do not know the special conditions 
that determine the occurrence of one or other form of these tubercular diseases. 
Negroes seem to be predisposed to them ; and exposure to cold and wet, and want 
of pure air and proper food and exercise, seem to favor their development. 

Pathology. — In scrofuloderma papulosum we are dealing with a tubercular peri- 
folliculitis ; the cell-accumulation is in the corium, more especially around the hair- 
papillae. Jacobi and Neisser have found both giant cells and tubercle-bacilli in 
the papillae. In the more extensive forms of tubercular infiltration they have also 
been found, but only in small numbers. 

Diagnosis. — The lesion in the papular form of the disease is characteristic, one 
or more groups of discrete, painless papules, occurring in youth, of chronic course, 
and presenting no subjective symptoms. A papular syphiloderm, with which it may 
be confounded, has copper-colored, hard papules arranged in circles, appears on the 
extremities also, and is almost always accompanied by other symptoms of the disease. 
Lichen planus has polygonal, purplish, flat-topped papules, with a central depres- 
sion. A papular eczema is more diffused, has vivid red acuminate papules, is accom- 
panied by itching, and some vesicles will be always found. 

The pustular scrofuloderm must be differentiated from the pustular syphiloderm. 
In the latter the infiltration is greater, the course is more rapid ; it is found oftenest 
on the face, more especially upon the forehead ; and other luetic lesions are generally 
present. Acne vulgaris is found on the face and back ; it is acutely inflammatory, 
and accompanied by comedones. 

The ulcerative scrofuloderm may be confounded with the gumma. But gum- 
mata occur mostly over bones, especially the sternum and tibia; they are harder, 
and run an acuter course ; the gummy discharge is characteristic ; they react to 
mercury and the iodide, of potash ; and other lesions of the disease can usually be 
found. After ulceration has occurred the scrofuloderma may be distinguished from 
the ulcerative syphilide by the sharp edges, extensive infiltration, pain, the circular 
or kidney shape, the good general health, the reaction to antiluetic treatment, etc., 
that characterize the latter. For the distinction of lupus vulgaris the exuberant 
granulations and the characteristic lupus nodules will suffice. 

No. 95. Crocker's Lead Thymol Ointment. 

fy Liq. plumbi subacet. . . 3 parts 
Thymol 1 part 

Petrolati . . . .100 parts 

Prognosis. — This is good; the scrofulodermata can usually be cured by appro- 
priate treatment. The patient is always liable, however, to infection of the internal 
organs or the general system. 



184 ILLUSTRATED SKIN DISEASES. 

Treatment. — In all cases the internal treatment is of the greatest importance, 
and should be essentially the same as for other tuberculoses. A nourishing diet, 
good hygienic surroundings, fresh air, and more especially sea air, with salt-water 
baths, are required. Cod-liver oil and creosote are useful. Shoemaker recommends 
the chlorate of potash. In scrofuloderma papulosum Neisser has used chrysarobin 
locally with remarkable effect. The treatment originally recommended by Hebra, 
cod-liver oil internally and externally, is as good as any that we can employ ; but 
it is disagreeable, since the skin must be kept soaked with the oil. Crocker recom- 
mends in its place a subacetate-of-lead ointment (No. 95, p. 183), cod-liver oil being 
used internally. The treatment of the pustular is very much the same as that of 
the papular form. Cod-liver oil or the iodoform plaster may be used locally. In 
the tubercular form, if the glands are softening and threaten to break down, arsenic 
should be given internally (No. 6, p. 46, No. 81, p. 158). Locally, if there is no 
fluctuation, a 10-per-cent. iodoform salve or the collemplastrum hydrargyri should 
be used. If fluctuation is distinct we can prevent unnecessary destruction of the 
skin by incision. A thorough curetting, followed by an iodoform gauze tampon, is 
the proper method to pursue. When ulceration has occurred the overhanging edges 
of skin should be cut away and the surface dressed with iodoform. If the granula- 
tions are exuberant they may be cut down with the nitrate-of-silver stick, or a I -per- 
cent, nitrate-of-silver salve, followed by pressure. 



TUBERCULOSIS CUTIS VERRUCOSA. 

Synonyms. — Verruca necrogenica, post-mortem, anatomical, or dissection tuber- 
cle, Leiclientuberkel (Ger.). 

Definition. — A local tuberculosis of the skin, appearing as a vesico-pustular erup- 
tion or a warty outgrowth, usually situated on the hands, and resulting from direct 
inoculation with the tubercular virus. 

Symptoms and Course. — At the site of an abrasion or wound there appear one or 
more vesico-pustules, situated on an infiltrated purplish area. The pustules dry up 
or are ruptured, and there begins a slow hypertrophy of the papillae at the affected 
point, which develop into a livid red warty growth, often fissured, and situ- 
ated on an infiltrated area of skin. Its progress is extremely slow, and it may 
persist for many years. Finally large, erythematous, infiltrated masses may be 
formed, with hypertrophic, warty, and fissured areas in their centers. Retrogressive 
changes occur spontaneously in the course of time, and a thin stellate or punctiform 
scar is left behind. The affection occurs in persons whose occupations bring them 
in contact with dead animals or their products, — cooks, butchers, hostlers, patholo- 
gists, etc., — as well as in those affected with tuberculosis of the lungs, and their 
attendants. It appears almost always on the backs of the fingers and hands, these 




COPYRIGHT, BY E. B. TREAT & CO. . N. Y. 



PHOTOGRAVURE 4 COLOR CO., N. Y. 



SYPHILODERMA PAPULOSUM 



PLATE XXXVII. 









the parts 

i 

because 
the grow 

- 
Etfolot 

ease : this has 
been den 

I ed 
pathologically 
by inocu- 
lation experi- 
ments on 










Diagnosis.- 

ficientl 

Prognosis. - 
that 

Treatment. — Tb 
effect! 

tinued applica .ercuriai 

and disappearance of la: 

e, causii 









:i 




i coto 



SYP 1 JLOSUM 






INFLAMMATIONS. 



185 



being the parts most exposed to local infection. In rare cases erysipelas, septicemia, 
pyemia, or gangrene occurs in connection with the process. The malady is rarely 
reported, possibly because of its slight extent at first and very slow progress, and also 
because many cases occur among physicians who do post-mortem work, who destroy 
the growth 
themselves. 

Etiology. — 

Infection with 
the tubercle- 
bacillus and its 
virus is the 
cause of the dis- 
ease ; this has 
been demon- 
strated both 
pathologically 
and by inocu- 
lation experi- 
ments on 

animals. 

Pathology. — 

The diffuse in- 
filtration is 
granulomatous 

in character, the papillary outgrowth and hyperkeratosis being secondary. Giant 
cells and the characteristic microorganisms have been found by Baumgarten and 
others. 

Diagnosis. — Its occurrence on the hands in persons whose occupations render 
them liable to such infection or who suffer from tuberculosis of the lungs, and the 
slow progress of the warty growth, sufficiently distinguish the disease. . 

Prognosis. — This is very good, provided none of the accidental complications 
that are mentioned above occur. 

Treatment. — This consists in the complete removal of the growth, which is readily 
effected, especially in the early stages. It may be done with the Paquelin or the 
galvanocautery, or with the curette, or by means of the mineral acids. The long- 
continued application of mercurial plaster will cause the gradual melting down 
and disappearance of larger growths. A good plan is to employ a strong salicylic- 
acid plaster for a time, causing the exfoliation of a part of the mass, followed up by 
the vigorous use of nitric acid. 




Fig. 92. — Tuberculosis cutis. 

From photograph by the author. 



186 ILLUSTRATED SKIN DISEASES. 



SYPHILIS. 

Syphilis, like the other granulomata, may affect any organ of the body ; but it is 
especially liable to show itself in the skin, and most cases of the disease come within 
the province of the dermatologist. It is essentially wrong to classify the malady as 
a venereal one. The virus of syphilis is non-volatile and cannot be transmitted 
at a distance ; prolonged contact with it, and probably the occurrence of a lesion of 
the skin or mucosae, are necessary for its implantation. These conditions occur most 
frequently during sexual congress, and hence the point of entrance of the virus is 
situated in most instances upon the sexual organs. But in a proportion of cases so 
large as to be estimated at 20 per cent, by some authorities it is seated elsewhere, and 
is transmitted by other than sexual acts ; and in another smaller proportion of cases 
it is gotten by heredity. Non-venereal syphilis, the syphilis insontium of Bulkley, 
is of sufficiently frequent occurrence to remove the disease from the small category 
of exclusively venereal maladies. 

There are many points of resemblance between lues and the infectious granulo- 
mata on the one hand, and the exanthemata on the other. Like tuberculosis and 
leprosy, syphilis is a locally contagious disease, gotten always and only by the direct 
transfer of a definite virus, which increases enormously in quantity during the 
course of the malady, and runs a definite course with appropriate symptoms. And, 
like the acute exanthemata, syphilis has its regular period of incubation, its point 
of primary invasion, its regular succession of phenomena, and its sequelae. It is 
really a chronic exanthematous disease. 

These facts are explicable only on the supposition that, like the maladies of the 
other two classes, syphilis is caused by the growth in the body of a living organism. 
Such a one has, indeed, been described by Lustgarten and others ; but positive 
proof of the exact nature of the etiological factor of luetic disease is still wanting. 

Ricord was the first to classify the phenomena of the disease chronologically ; 
and, although we have learned that his order is not an invariable one, it is suffi- 
ciently accurate to be of use, and has been generally accepted. After a period of 
primary incubation of from four to six weeks, during which the patient, though 
infected, shows no sign of disease, there begins the first or primary stage of the 
malady, marked by the appearance of the chancre or sclerosis at the site of inocula- 
tion of the virus, together with swelling of the adjacent lymphatic glands. This 
stage lasts some four to eight weeks. Then occurs another period of quiescence of 
from six to twelve weeks, the period of secondary incubation, during which the 
patient is apparently well, save perhaps for the presence of the remains of the pri- 
mary lesion. This is followed by the secondary stage of the disease, marked by 
general constitutional symptoms and fever, swelling of all the lymphatic glands of 
the body, generalized eruptions, mucous patches, cephalalgia, angina, etc. It lasts 
for a varying number of months, and is followed by a third period of quiescence of 



INFLAMMATIONS. 



187 



varying length. Finally there occurs in many cases a third stage, lasting for an 
indefinite number of years, in which occur the sequelae of the disease — the more cir- 
cumscribed and deeper-seated eruptions, gummatous and ulcerative lesions, and the 
affections of the bones and the internal organs. 

Not all cases, however, exhibit this regular succession of stages separated by 
periods of quiescence. The tertiary stage may be entirely absent, or its character- 
istic lesions may occur very early in the course of the malady. The first and sec- 
ond stages, however, are never absent in any case of the disease. 

We are only concerned here with those phenomena of syphilitic disease that 
occur on the skin and the mucosas, and we shall consider: I. The chancre; 2. The 
macular syphiloderm ; 3. The papular (squamous) syphiloderm ; 4. The pustular 
syphiloderm ; 5. The tubercular syphiloderm; 6. The gummatous syphiloderm; 7. 
The ulcerative syphiloderm ; 8. Syphilis of the hair and nails ; 9. Hereditary syphi- 
lis, which differs in some important respects from the acquired variety, and demands 
separate consideration. 

CHANCRE. 

Synonyms, — Hard chancre, initial lesion, sclerosis, ulcus durum. 

Definition. — The primary lesion of syphilis, appearing at the point of inoculation 
of the virus of the disease. 

Symptoms and Course. — A chancre is not a definite lesion, since it may appear 
as a papule, a vesicle, an erosion, or an ulceration ; but it is a disease entity, because 
the distinctive symptoms of induration and 
adenopathy always accompany it, and con- 
stitutional syphilis always follows it. It 
appears, on the average, twenty-one days 
after inoculation ; but the limits of the 
period of primary incubation are wide, 
and it may show itself from ten days to 
ten weeks after the infection. In its com- 
monest form it begins as a minute desqua- 
mating papule, and grows to be a moder- 
ate-sized, flat tubercle. In many cases it 
is an insignificant lesion, and, especially 
when located inconspicuously, as in the 
vagina, it may never attract the patient's 
attention. The skin over the papule may 
be merely reddened, or it may be eroded 
or ulcerated ; and the ulceration may be 
shallow, with a smooth, shiny base and 
scanty, viscid secretion, or it may be deep 

and covered with diphtheritic sloughs and From photograph by the author. 




188 



ILLUSTRATED SKIN DISEASES. 



fragments of necrotic tissue. In rarer cases the lesion may be vesicular or even 
bullous from the beginning. 

In almost all cases, however, there occurs after a time in the lesion a hardness or 
induration that is typical and has given it a name. It varies in density, but is 
usually cartilaginous to the touch. It may be so small in amount as to feel like a 
thin sheet of wax, " let in," as it were, into the base of the lesion; or it may be so 
extensive and thick as to be visible to the naked eye when the tissues are moved. 
It may be quite small, \ of an inch in size, or it may be i^- inches or more in diameter. 
It is the real lesion, the chancrous tumor itself; the appearance of the surface change 
being determined in each case by other and usually adventitious circumstances. 

A second and characteristic concomitant of the chancre is the hard, stony, pain- 
less swelling of the lymphatic glands belonging to the tissue involved. A third one 
is the invariable occurrence, after a period of secondary incubation of some weeks, 
of some of the phenomena of constitutional syphilis. 

The seat of chancre is most often upon the genitals, since those are the parts 
most exposed to contagion. It is common upon the glans penis, especially around 

the meatus, on the sulcus and frenum, and on the 
prepuce ; in the female it is most often seen upon 
the labia. But it is not infrequently seen on the 
thighs, lips, nipples, fingers, and other parts of the 
body. Its location depends upon accident, and 
I have observed it upon the forearm of a nurse 
who carried around a half-clad syphilitic child, 
and on the neck of a woman as the result of 
the over-affectionate kiss of a long-absent hus- 
band. 

The chancre is generally a single lesion, but 
sometimes there are two or more, usually on con- 
tiguous parts. Its termination is in resorption ; 
the papule or ulceration soon disappears, but it 
may be months or years before the last traces of 
the induration vanish. A pigmented spot, more 
rarely a scar, is left behind. Very characteristic is 
the almost entire absence of pain and tenderness, 
except when the ulceration is extensive and the 
sclerosis is complicated with other infection. Other 
complications are, in the first place, chancroid, 
which is frequent and often obscures the diagnosis ; phimosis and paraphimosis ; gan- 
grene ; and, in debilitated subjects, phagedena. 

Etiology. — The cause of the chancre is the same as yet unknown living organism 
that causes the general disease. 




Fig. 94. — Exulcerated chancre. 

From photograph by the author. 




COPYRIGHT BY E. B. TREAT &. CO. , N. Y. 



PHOTOGRAVURE i. COLOR CO., N. Y. 



SYPHILODERMA PAPULO-PUSTULOSUM 



PLATE XXXIII 












Pathology. — The chanc 
cell infiltration, very similar 

The cause of the peculiar indu 
claim that it is due to an excessive ( 
incloses and subdivides the cell-ma 
Diagnosis. — Although its initial 
the full '■ chancre pos 

a suspicious integr- 
ation and r 
induration >tic - 

retion - ; but, above all, th 
stony, painless polygangliar lymphadeni- 
tis, progres \ idually from the lym- 
phatic glands nearest to the lesion to mo 
distant ones until those of the entice 
are involved— all these symptoms are char- 
acteristic. But the diagnosis from chan- 
croid is often difficult and s ^es im- 
possible. This is especially the case 
udicious use 
• uncertain natr 
mal 

with undermined ed 
tion 

painful 

have occurred, and the • 

upon the patient at one and 

teristics of the purely I 

the infecting chanc 

appearing as circula short-lived 

I accompanied neither by the indurati 

inflamed by i 
In view isiderati: 







! 



terizi 
inter! 










■LODERM ">UM 



PLATE 



INFLAMMATIONS. 



189 



Pathology. — The chancrous tumor is a granuloma of the cutis, a dense round- 
cell infiltration, very similar to those that characterize the later stages of the disease. 
The cause of the peculiar induration is still a matter of doubt. Some authorities 
claim that it is due to an excessive development of the fibrillar connective tissue that 
incloses and subdivides the cell-mass. 

Diagnosis. — Although its initial appearance varies greatly, as has been stated, 
the fully developed chancre possesses fairly well-marked features. Its advent two 
or three weeks after a suspicious inter- 
course ; the tumor-like elevation and the 
induration ; the absence of pain and notice- 
able secretion ; but, above all, the indolent, 
stony, painless polygangliar lymphadeni- 
tis, progressing gradually from the lym- 
phatic glands nearest to the lesion to more 
distant ones until those of the entire body 
are involved — all these symptoms are char- 
acteristic. But the diagnosis from chan- 
croid is often difficult and sometimes im- 
possible. This is especially the case when, 
by the early and injudicious use of caustics 
on a sore of uncertain nature, an inflam- 
matory induration has been set up that 
may closely resemble the specific one. 
Chancroid, indeed, is usually multiple, be- 
ginning as a round, deeply cut ulceration 
with undermined edges ; it has an incuba- 
tion of a few hours or a day or so, with the 
painful suppurating buboes, and is auto-inoculable. But a mixed infection may 
have occurred, and the chancrous and chancroidal virus may have been inoculated 
upon the patient at one and the same time ; and a sore that presents the charac- 
teristics of the purely local lesion may in the course of time develop all the signs of 
the infecting chancre. Herpes of the genitals also, though usually multiple, and 
appearing as circular, shallow, short-lived erosions, unconnected with intercourse, 
and accompanied neither by the induration nor by the characteristic glands, may be 
so inflamed by irritating applications as to look not unlike an initial lesion. 

In view of these considerations, and on account of the great practical importance 
of a decision as to the presence or absence of syphilis, it is well to make a probable 
and not a positive diagnosis of any suspicious lesion of the genitals until at least the 
ordinary period of incubation of the systemic disease has passed ; to treat with cau- 
terizing agents only such chancroidal-looking sores whose extension demands active 
interference ; and to treat all other suspicious lesions with mild local measures alone 




Fig. 95.— Chancre of the lip. 

From photograph by the author. 



190 



ILLUSTRATED SKIN DISEASES. 



until the appearance or non-appearance of definite signs of systemic infection — poly- 
adenitis, angina, exanthem, etc. — settles the question. 

Prognosis. — A chancre is a lesion of small importance in itself, since it rarely 
causes discomfort, permanent injury, or deformity. The location or mode of origin 

of the lesion has no connection with the 
severity of the systemic disease. There 
are, however, reasons for believing that the 
smaller the sclerosis, and the freer it is from 
ulcerative and other complicating processes, 
the less severe the subsequent manifesta- 
tions will be. 

Treatment. — Prophylaxis consists in a 
search for lesions of the skin and mucosae 
after a suspicious contact, their cauteriza- 
tion when found, and the use of cleansing 
and disinfectant solutions ; above all, of 
course, in the avoidance of intercourse or 
contact in any form with known syphilitics. 
When the chancre has appeared, its ex- 
cision with the knife or its destruction with the Paquelin cautery has proved to be 
of no use at all. The mercurial collemplastrum should be put on the sclerosis and 
on the indurated glands, or the ordinary mercurial plaster or ointment may be em- 
ployed ; and it should be continued until the hardness has entirely disappeared. 
If ulceration occurs, calomel, iodoform, or aristol may be used locally as a powder. 
Constitutional treatment should only be begun when the diagnosis is definitely set- 
tled by the appearance of secondary symptoms. 




Fig. 96. — Chancre of the meatus. 

From photograph by the author. 



SYPHILODERMA. 

Synonyms. — Dermatosyphilis ; syphilis cutanea ; syphilides. 

Definition. — Macular, papular, vesicular, pustular, squamous, gummatous, or 
ulcerative eruptions, affecting the skin and its adnexa and the mucosae, and caused 
by systemic infection with the virus of syphilis. 

Symptoms and Course. — Although cutaneous syphilis appears in a variety of 
forms, the lesions in each case are generally of one kind only, and polymorphism 
like that of eczema does not occur. Many of them bear a close resemblance to 
other diseases, and the question of differential diagnosis is often a most important 
one. The manifestations are not, as a rule, accompanied by general symptoms or 
marked subjective sensations. A fever, sometimes quite high, with headache, ano- 
rexia, and muscular pains, may usher in the early secondary eruptions ; but it is 
usually entirely absent. The deeper ulcerative lesions are sometimes painful, 



INFLAMMATIONS. 



191 



but more often the patient has no complaint to make, and the eruption is sometimes 
discovered accidentally. With the early syphilodermata we usually find the sclero- 
sis or its remains, the local and general adenopathy, the angina, the headache, etc. 
With the later ones there are often the osteocopic pains, the permanent alopecia, and 
the cicatricial remains of previous lesions. The lesions themselves may be macular, 
papular, tubercular, vesicular, pustular, squamous, bullous, gummatous, or ulcerative 
in form; occasionally two or more varieties are present at one and the same time. 
They are found anywhere on the body, but some of them show preferences for cer- 
tain locations. The early 
eruptions are more or less 
general and superficial, and 
are most commonly macular 
or papular. The erythema- 
tous eruptions are usually 
most plainly seen upon the 
trunk ; the papular ones are 
most prominent about the 
genitals ; the tubercular forms 
reach their greatest develop- 
ment upon the face and neck ; 
and the papulo-squamous 
lesions are commonest upon 
the palms and soles. In all 
forms the lesions show a tend- 
ency to assume a circular, 
semicircular, or crescentic 
shape ; this is most marked, 
however, in the later circum- 
scribed manifestations. In all 
save the macular forms the 
lesions are sharply limited in- 
filtrations, elevated and mod- 
erately hard to the touch. 
Their color is peculiar. At 

first bright red, "they soon fade into a dull brownish red or coppery hue, which is 
commonly likened to the color of lean ham. These infiltrations are incapable of 
higher organization ; they finally retrogress, and disappear by fatty degeneration and 
absorption or ulceration. In the later localized forms the infiltrations break down 
and ulcerate in their central older portions while the infiltration is still progressing 
at the periphery ; and thus crusts of varying thickness covering ulcers with hard' 
infiltrated margins are formed. 




Fig. 97. — General macular syphiloderm. 
From photograph by the author. 



192 



ILLUSTRATED SKIN DISEASES. 



i. Syphiloderma maculosa, roseola s. erythema syphiliticum, the erythematous 
or macular syphilide, is the commonest general cutaneous manifestation of the dis- 
ease, and is sometimes the only one. It 
appears from the third to the tenth week 
after the advent of the chancre, and, 
being unaccompanied by itching, pain, or 
desquamation, is often not noticed by the 
patient. It shows itself as lentil- to 
finger-nail-sized, non-elevated, and usu- 
ally discrete spots ; but sometimes the 
eruption is more or less confluent, giving 
rise to a general mottling of the integu- 
ment. Its seat is on the trunk, and it is 
especially noticeable upon the back ; the 
face nearly always escapes. Its color is 
at first pale rose red, and fades away 
completely under pressure ; but later it 
assumes a darker hue, and yellowish- 
brown stains are left behind when it 
passes away. Occurring with it are usu- 
ally the polyadenitis, the angina, the 
defluvium capillorum, and other early 
signs of the disease, together with the 
remains of the sclerosis. A later macu- 
lar eruption, the roseola figurata or an- 
nulata, also occurs, in which the spots are 
larger and often arranged in crescentic 
or ring shapes. Circumscribed or con- 
fluent reddened areas occur on the mu- 
cosae coincident with the roseola. 

2. Syphiloderma papulosa, the papu- 
lar svphilide, occurs with large and with 
small papules, forming two varieties of 
the exanthem sufficiently different to 
require separate descriptions. The large 
papular syphiloderm is a common form 
of specific eruption, appearing usually 
about three months after the infection ; 
less frequently it is seen as a late or 
tertiary lesion. Often it immediately 

succeeds the roseola or occurs together 
5. — General papular syphiloderm. . 

From photograph by the author. with it, the papules developing in the 





COPYRIGHT BY E. B. TREAT & CO., N. Y. 



PHOTOGRAVURE AND COLOR CO., N. Y. 



SYPHILODERMA PAPULOSUM 



PLATE XXIX. 






•1 



hard nodule 

a large number of them 
i ii 

::>e affected, . 

>rms th 

: s. In th . 
the p; atively fe 

tendency to circular grouping is m 

egular cr 
papules in variou 

;ion are present a: one ai d 



They increas 



' 



- 









- 



the i 

• Ij 

■ 























et pi 



>yp 

stinate and chron 








SYP; MA PAPULC 



PLATE 



INFLAMMATIONS. 



193 






'•- 



u 



center of the macules, and rapidly increasing in size (syphiloderma maculo-papulosa). 
The fully developed papules are lentil- to pea-sized, or even larger, sharply limited, 
hard nodules, conical or flat, and with smooth, shining tops. Their color is a cop- 
pery red that does not disappear under pressure. In the early and commoner form 
a large number of them are scattered irregularly over the entire body, with some 
tendency to grouping in circles, or segments 
of circles, or curved lines. The face is espe- 
cially apt to be affected, and a row of papules 
on the upper part of the forehead near the 
margin of the hair forms the commonest va- 
riety of the corona veneris. In the later forms 
the papules are comparatively few, and the 
tendency to circular grouping is more marked. 
The lesions come in irregular crops, so that 
papules in various stages of growth.and retro- 
gression are present at one and the same time. 
They increase slowly by peripheral growth, 
remaining stationary for weeks or months as 
fully developed papules ; and then they grad- 
ually disappear by fatty degeneration and ab- 
sorption, leaving behind atrophic spots, which 
at first are pigmented, and later become 
white. 

Some scaling marks the process of invo- 
lution, and this, when extensive, gives rise to 
the variety known as syphiloderma papulo- 
squamosum. Here the papular lesions above 
described are covered with a greater or less 
amount of dry, grayish, partially adherent 
scales ; and, as the central oldest portion of 
the papule" undergoes involution and loses its 
scales while the peripheral portions are still 
advancing, we get a very characteristic collar 



of semi-detached scales at the margin of the 




FlG. 99. — Papular plantar syphiloderm. 

From photograph by the author. 



infiltration. Adjacent papules may coalesce, 

forming more extensive infiltrated and scaly 

patches, especially in the later and more circumscribed forms, and closely resembling 

a psoriasis. 

In certain localities the large papular syphiloderm differs greatly in appearance 
from the above-described typical form; this is notably the case on the palms and 
soles and around the muco-cutaneous orifices. Syphiloderma papulosum palmarjs 
et plantaris is a very obstinate and chronic form of the malady ; it occurs as an 



194 



ILLUSTRATED SKIN DISEASES. 



early lesion from four to six months after infection, and is also a common late mani- 
festation. The early palmar syphiloderm appears as lentil-sized papules symmetri- 
cally distributed over both palms and soles, and of a reddish, coppery color ; but, on 
account of the thickness of the corneous layer in these locations, the lesions are 
not perceptible to touch. Central scaling appears after a time, and this scaling 
extends to the periphery as involution begins in the oldest portion of the infiltra- 
tion. Thus the fully developed eruption appears as isolated or confluent purplish- 
copper-colored macules, each surrounded by a margin of semi-detached scales. The 

later form may occur many years 
after infection ; it is very intract- 
able and it may last a long time. 
Here the papules are usually fewer 
in number and arranged in a group; 
one palm or one sole only is gen- 
erally affected. It appears as a 
rounded patch of varying size, with 
an atrophic center where the pap- 
ules have already disappeared, and 
an inflammatory margin composed 
of a row of deep-seated papules 
with grayish-yellow, semi-detached 
scales. Fissuring of the skin is nut 
uncommon from the pressure of the 
infiltration, and localized keratoses, 
hypertrophies of the epidermis, and 
papillary outgrowths also occur. 

When the large papular syphi- 
loderm occurs in the neighborhood 
of the mucous orifices, or in loca- 
tions where folds of the skin are in 
juxtaposition, so that maceration ot 
the papules with sebum and sweat 
occurs, as between the folds of the 
buttocks, around the genitals, in the 
axillae, the submammary regions, and between the toes, its lesions undergo a peculiar 
hypertrophic modification, and are known as condylomata lata. These may occur 
alone, or together with a general papular eruption ; and the identity of the lesions is 
shown by the fact that when the condylomata are kept clean and dry they become 
ordinary papules. They appear as reddish flat or button-shaped outgrowths ; they 
may be pea- or bean-sized when derived from a single lesion, or form larger cauli- 
flower-like masses when formed by the coalescence of neighboring hypertrophied 




Fig. ioo. — Condylomata lata. 

From photograph by the author. 



INFLAMMATIONS. 195 

papillae. They are elastic to the touch, and have a smooth or papillary surface, 
usually covered with a grayish, very foul-smelling secretion. They generally occur 
symmetrically, the opposing layer of skin being directly irritated and infected. Super- 
ficial erosion is frequent, and the lesions may even undergo ulceration and lead to 
the formation of cicatrices ; but they generally disappear by involution, a pigmented 
spot that subsequently becomes white being left behind. Condylomata lata usually 
occur during the first years after infection, but are very prone to relapse. Their 
secretion is very contagious. 

On the mucous membranes themselves, or in localities of the skin where, from 
the approximation of its folds, the conditions as to heat and moisture resemble those 
of the mucosas, the large papular syphiloderm appears as the mucous patch {plaque 
uiuqueuse [Fr.], nassende Papel, Scldeimpapel [Ger.]). This is a very frequent 
lesion of syphilis, occurring early in the disease as well as in its later stages, and is es- 
pecially common in women. The mucous patches are seen in the mouth and throat 
and upon the tongue, in the external auditory canal, the vagina, the anus, the 
preputial cavity, the scrotum, the interdigital spaces of the toes, the umbilicus, etc. 
They may be regarded as macerated and eroded papules, whose peculiar appearance 
is caused, as in the case of the hypertrophic papules known as condylomata, by local 
conditions. They appear as small pea- to finger-nail-sized areas of rounded outline, 
and are usually whitish or grayish in color, on account of the delicate transparent 
gray pellicle, composed of sodden epithelium and exudation, that covers the inflamed 
or eroded area. They are sometimes accompanied by fissures, and occasionally they 
are the seat of papillary or warty outgrowths. Mucous patches are exceedingly 
contagious, and are probably a much more frequent source of syphilis than the initial 
lesion itself. 

The small papular or miliary papular syphiloderm is rarer than the large form ; 
and occurring, as it usually does, in tubercular or otherwise debilitated subjects, it 
indicates the presence of a severe type of the disease and is usually of a bad 
prognosis. It is seen as a generalized eruption occurring early, three months or 
later after infection, or as a later more localized and grouped affection. The lesions 
are conical, millet-sized, coppery-brown papules, abundantly scattered over the body 
or grouped into irregular circular areas. It is especially prone to occur on the face 
and forehead, in which latter situation it forms one variety of the corona veneris. 
The papules in the course of time become scaly, but the amount of scaling is very 
much less than in the large papular form. After persisting for a varying time, 
involution by fatty degeneration occurs, and brownish spots with central atrophic 
depressions are left behind. The miliary papular syphiloderm is an obstinate erup- 
tion and very prone to recur. 

3. Syphiloderma pustulosa is a rarer manifestation of acquired syphilis than the 
preceding forms, and, since it occurs in marasmic subjects, is of more serious prog- 
nosis. It may be pustular from the beginning, or it may develop from the papular 



106 



ILLUSTRATED SKIN DISEASES. 



form after a brief vesicular stage, in which case it is probable that infection with 
pus-cocci is the factor that prevents the normal involution of the papule. The 
pustules vary much in size, number, course, depth of tissue invaded, and it has been 
customary to designate them by the names of the non-syphilitic lesions — acne, vari- 
ola, impetigo, ecthyma, etc. — that they resemble. The early forms are more super- 
ficial, disseminated over the body, and often accompanied by constitutional symptoms, 

fever, etc., while the later forms are 
grouped and more discrete, and lead 
to deeper destruction of tissue. 
We may distinguish a large and a 
small pustular syphiloderm. 

The large pustular syphiloderm 
(ecthyma and rupia syphilitica) 
rarely occurs as a general eruption 
in acquired syphilis, being com- 
moner in the later circumscribed 
and the hereditary forms of the dis- 
ease. As a general exanthem it 
appears after the sixth month or 
later, beginning as an eruption of 
papules more or less thickly scat- 
tered over the back, shoulders, and 
extremities, and soon developing 
into small pea- to bean-sized flat 
pustules, surrounded by dark-red, 
sharply limited, infiltrated areolae. 
The pustules soon rupture or dry 
up into dirty brown crusts, under- 
neath which is a more or less deep, 
irregular ulceration ; and they heal 
with the formation of a circular, de- 
pressed scar. The circumscribed 
forms occur later, rarely before the end of the first year. Here the pustules are 
few, isolated, and large ; and they dry up into thick greenish-brown or black crusts, 
under which are deep, irregular, steep-walled ulcerations, with dark-brown or more 
frankly inflammatory walls of infiltration around them. Still more circumscribed 
is the form known as rupia, which begins as large, flat, isolated pustules, which dry up 
into superficial crusts. The infiltration progresses at the margins as breaking down 
and suppuration extend from the center; new rings of suppuration are formed 
around and under the central crust, which in their turn dry up. Thus the older por- 
tions are gradually raised up by successive and more extensive layers of dried pus, 




Fig. ioi 



Pustular syphiloderm 
(negress). 

From photograph by the author. 




COPYRIGHT, BY E. B. TREAT £ CO. , N. V. 



PHOTOGRAVURE & COLOR CO., N. V. 



SYPHILODERMA PUSTULOSUM 



PLATE XXXIX. 






ug us the pecuii and 

surrounded by the red, 
deep, irregular V 
s pus. This form of 
and if, a? is frequently the ca s at 

one margin while healing at 
.e kidne 

small pustular or miliar) 
either acumina 
• 
beii. o split pea i 

variety may occur in an e<v 
later more circumscribed form. -eral 

eruption the acuminate pustules beg iical 

vesicles, the contents of 
purulent and dry up into 

or collaret of partia Hum 

surrounds the ci 
scar be: 

j.irts. In the small, 








- . 

'hat Hfrfr.r.- 
disease. 

subjacei t in the ;'■ 

superfici:. 

4. Syp rculosa is a _Gen< 

form of skin 
respects, save as 

the lesion's, to the large popular eruj 
; before the second year 

■ 

dark or ng tops, 

in size. are 

general iked ten 



- 



INFLAMMATIONS. 



197 



giving us the peculiar oyster-shell crusts resting on the pus-filled ulcerations, and 
surrounded by the red, infiltrated, advancing margins. Removal of the crusts re- 
veals a deep, irregular loss of tissue, with a dirty, uneven base covered with an icho- 
rous pus. This form of pustular syphiloderm may be very chronic, lasting for years ; 
and if, as is frequently the case, it advances at 
one margin while healing at the other, it gives 
rise to the kidney-shaped serpiginous ulcerations 
that are so characteristic. 

The small pustular or miliary pustular syphi- 
loderm may be either acuminate or flat (acne, 
variola, and impetigo syphiliticum), the pustules 
being millet seed to split pea in size. Either 
variety may occur in an early generalized or a 
later more circumscribed form. As a general 
eruption the acuminate pustules begin as conical 
vesicles, the contents of which rapidly become 
purulent and dry up into minute crusts. A fringe 
or collaret of partially desquamated epithelium 
surrounds the crust, and it leaves a small deep 
scar behind when it falls off. It is especially 
prone to attack the hairy parts. In the small, 
flatter form the lesions are more numerous, espe- 
cially upon the trunk and face ; and as their out- 
break is often accompanied by fever and general 
constitutional disturbance, it may be difficult to 
distinguish it from variola, especially in the col- 
ored races. I have seen case after case of this 
variety of luetic eruption sent to the hospital as 
cases of smallpox during an epidemic of that 
disease. The crusts eventually dry up, and the 
subjacent ulcerations result in the formation of 
superficial scars. 

4. Syphiloderma tuberculosa is a rather rare 
form of skin syphilis, and corresponds in most 
respects, save as regards the size and number of 
the lesions, to the large papular eruption. It is essentially a late form, rarely occur- 
ring before the second year, and being often seen ten, twenty, or more years after 
infection. The lesions appear as rounded, firm, semiglobular or irregular elevations, 
dark or coppery red in color, with smooth, shining tops, and coffee-bean to large nut 
in size. Usually a few only are present, and there are never very many ; they are 
generally closely aggregated, and show a marked tendency to assume a circular, semi- 




Fig. 102. 



General pustular syphiloderm 
(negro). 

From photograph by the author. 



198 



ILLUSTRATED SKIN DISEASES. 




Fig. 103. — Tuberculo-squamous syphiloderm. 

From photograph by the author. 



circular, or cres- 
centic arrange- 
ment. They are 
generally confined 
to certain regions, 
and are commonest 
on the face and 
neck. Growth is 
very slow, but in 
the course of time 
the tubercle may 
reach the size of 2 
inches or more ; 
and, as it com- 
monly spreads on 
one side only, it is 
very prone to as- 
sume the horseshoe 
or kidney shape. 
The lesions go on 
finally to fatty de- 
generation and interstitial absorption, and leave pigmented scars or atrophic areas 

behind ; or they break down and ulcerate, with 

or without the formation of rupial crusts. Their 

irregular mode of extension causes them to become 

serpiginous, spreading slowly in a definite direction 

over the skin ; and this is the case with both the 

ulcerative and the non-ulcerative forms. Papillary 

out-growths from the ulcerated tubercles occasion- 
ally occur, giving us the form known as syphiloder- 

mata papillomatosa, with warty, cauliflower-like 

excrescences covered with an offensive, yellow, 

puriform discharge. 

5. Syphiloderma gummatosum. The gumma 

or syphiloma is the commonest lesion of late syphi- 
lis, and occurs in the internal organs as well as on 

the skin. In the rare malignant cases it is multiple 

and occurs early ; but more often one or a few only 

are present, appearing not before the third or fourth 

year after infection, and possibly ten, twenty, or 

more years thereafter. It appears as a various-sized, FlG - 104. —Hypertrophic tubercular 

a j 1 1 1 1 t • i 1 • 1 syphiloderm. 

flat or rounded, globular or oval, indolent, painless case of Professor Hsenberg,Wanaw, Poland. 




INFLAMMATIONS. 



199 




tumor, and is not usually accompanied by 

any constitutional disturbance. It grows 

slowly for weeks or months till it attains 

the size of a walnut or an egg. Then it 

begins to soften in the center, and the skin 

covering it becomes reddened and adhe- 
rent, giving it a deceptive resemblance 

to a chronic abscess. Involution may be 

accomplished by interstitial absorption, 

with sinking and atrophy of the skin ; but 

more commonly the thin covering of the 

tumor breaks, and a thick glairy fluid, 

more or less mixed with detritus and pus, 

is poured out, leaving a deep circular or 

irregular ulcer, with an uneven base cov- 
ered with necrotic tissue and pus. This 

finally heals by granulation, cicatrization, 

and the formation of smooth, circular, 

white, and often adherent scars. 

Two forms of gummata of the skin are 

to be distinguished — the superficial and 

the deep. The superficial variety usually 

consists of circumscribed groups of pea- to 
hazelnut-sized tumors arranged in a crescentic 
or circular form. The infiltration often increases 
on one margin while involution, either by inter- 
stitial absorption or by ulceration, advances on 
the other, giving us the creeping or serpiginous 
form of gummatous infiltration of the skin. The 
deeper forms are larger, egg to orange size ; I 
have met them 6 inches in diameter. There is 
usually a single tumor, or at most three or four ; 
yet there are exceptions, and I have recorded 
a fatal case in which death from exhaustion 
occurred, and in which there were no less than 
sixty deep cutaneous gummata, most of them 
2 or 3 inches, and some of them 6 inches in 
diameter. 

Gangrene and phagedena sometimes occur, 
with deep and wide-spread destruction of tis- 
sue, so that the aponeuroses, muscles, and even 

Fig. 106. — Exulcerated gumma of the knee. . , . ,, -^. i j 

From photograph b y the author. the bones are laid bare. The exulcerated gumma 



FlG. 105. — Superficial gummata. 
Case of Professor Elsenberg, Warsaw, Poland. 




200 



ILLUSTRATED SKIX DISEASES. 



sometimes develops exuberant granulations, which form fungoid masses, the fram- 
bcesia syphilitica. Gummata also occur on the mucosae, but cause little subjective 
trouble and have usually reached the ulcerative stage before their presence is de- 
tected. 

6. Syphiloderma ulcerosa is not a distinct form of the disease, but occurs as the 
terminal stage in the papular, tubercular, pustular, and gummatous syphilodermata. 

The ulcers have certain characteristic features. 
Their margins are infiltrated, elevated, sharply lim- 
ited, and dark red ; their edges are undermined ; 
and their bases are irregular, and covered with 
grayish-yellow fragments of necrotic tissue. Their 
shape is round, oval, or kidney-like, and they are 
often covered with thick, greenish-black, heaped - 
up (rupial) crusts. They leave thin, rounded scars, 
that are at first red and later white, and that are 
movable or adherent in accordance with the depth 
of tissue involved in the destructive process. Super- 
ficial ulcerations arise from papules, tubercles, or 
superficial gummata, and are round, reniform, or 
irregular in shape ; deep ulceration, arising from the 
deeper cutaneous or the subcutaneous gummata, 
is irregular and crateriform. 

7. Syphilis of the hair and nails. The syphi- 
litic virus may affect the nutrition of the nails, giv- 
ing rise to various forms of onychia; or the inflam- 
matory lesions characteristic of the disease mav 
appear in or around the matrix, causing paronychia. 
In onychia, which is non-inflammatory, the nail loses 
its luster and becomes dry and brittle ; furrows and 
ridges appear on its surface ; its free edge is thickened and filled with dirt ; it breaks 
off irregularly, and portions of the nail itself may be cast off, leaving the nail-bed 
exposed. Or, again, the entire nail may become gradually detached and shed, a 
white line marking the point of division between it and the new nail that gradually 
grows up behind it. All the nails of the fingers and toes, or most of them, are 
usually involved. The affection occurs in the early stages of the disease, coincident 
with the other nutritive changes. 

Paronychia syphilitica is an inflammatory lesion beginning in the tissues around 
the nail and gradually extending to its bed. Papules or pustules may appear as 
part of a general eruption, or as isolated lesions, at the margins of the nails. The 
papules may be visible through the nail as brownish-red spots, and the pustules may 
raise the entire nail from its bed and destrov the matrix. Around the margins of 




Fig. 107. — Gumma subcutanea. 
From cast by the author. 




SYPHILODERMA PAPULOSUM. 




• ._ 



«f 



* ■ 



: t 








TYPOGRAVURE. 



COPYRIGHT, 1903, Br E. 6. TREAT 4 CO., N. 



SYPHILODERMA POSTULOSUM. 



PLATE XXVII. 



••■ ■ 



nmatory 

iiation of the epid 
re commonly frankly inflammatc 
in the groove rounded 

tion not infreque: severe' 

of the dist< »ns spring 

md a 

The nail 

d, and is 

by cicatricial 
In b n of the 

phak in the inflammatory 

process. Gummatous infiltration of the 
matr : subsequent ulc 

occurs. Paronychia n the 

early second: lilitic dis- 

ease, but mma 



rhea, bu 
flammate" 

alope >mplete ; 

ally , the 

in as the nes 

under t 

In the later stages of 
atrophic or u 
►ns of that pc 











■i 







OSTUL'. 



INFLAMMATIONS. 



201 



the nail the inflammatory process may be chronic and manifest itself as a hyper- 
trophy and exfoliation of the epidermic scales ; but, in my experience, it is much 
more commonly frankly inflammatory. The papules at the margins of the nail and 
in the groove coalesce, and a rounded or oval dusky-red swelling is formed. Ulcera- 
tion not infrequently occurs in severe types 
of the disease ; fungous granulations spring 
up and cover the edge of the nail ; and a 
fetid pus exudes from the mass. The nail 
becomes discolored and loosened, and is 
finally cast off ; and the nail-bed, destroyed 
wholly or in part, is replaced by cicatricial 
tissue. In bad cases the skin of the entire 
phalanx is involved in the inflammatory 
process. Gummatous infiltration of the 
matrix, with subsequent ulceration, also 
occurs. Paronychia is commonest in the 
early secondary stage of the syphilitic dis- 
ease, but it may occur at any time ; gumma 
of the nail is a late lesion. 

The hirsute appendages of the skin suf- 
fer more commonly than do the nails from 
the effects of the syphilitic poison, and alo- 
pecia syphilitica is a fairly constant symp- 
tom of the disease. From four to five 
months after infection, and later, the hair 
becomes dry and lusterless, and the diffuse 
falling out, giving the head a characteristic 
moth-eaten appearance, occurs. This is 
sometimes accompanied by a dry sebor- 
rhea, but more commonly there are no in- 
flammatory symptoms whatsoever. The 
alopecia is very rarely complete ; and the 
hair usually, though not always, grows in 
again as the poison of the disease becomes 
less virulent under the influence of time and 
treatment. In rare cases the hair of the axillae, eyebrows, beard, etc., also falls out. 
In the later stages of the disease a permanent alopecia may occur in consequence of 
atrophic or ulcerative changes in the scalp after papular, tubercular, or gummatous 
lesions of that portion of the body. 

8. Hereditary syphilis. In hereditary syphilis the fetus is infected in utero by 
one or both parents ; and the disease thus acquired differs in some respects from 




Fig. 108. — Ulcerative syphiloderm. 
Case of Dr. H. Roth. 



202 



ILLUSTRATED SKIN DISEASES. 




the more ordinary variety. The initial sclerosis is absent, and the regular order of 
the phenomena, so marked in most cases of the acquired variety, is entirely lost. 

The so-called secondary and tertiary 
lesions may occur together, or the 
latter alone may be present ; gum- 
mata may appear in utero or at birth, 
and irritative lesions later on. The 
virulence of the disease depends on 
the age of the parental infection and 
the thoroughness of the treatment 
that has been employed. In the 
worst cases the fetus dies in utero, 
and abortion results. In others a 
living child, small, ill developed, with 
wrinkled skin, a characteristic " old- 
man " appearance, and showing one 
of the eruptions to be described be- 
low, is born. Coryza (" snuffles ") 
appears ; the voice is hoarse and 
squeaky ; the skin of the palms and 
soles is red and shining; marasmus 
soon sets in; and the child dies of diarrhea or visceral complications. Again, the 
child may be born apparently perfectly health}-, but soon becomes weak and sickly, 
and the symptoms above enumerated, with a charac- 
teristic eruption, appear. The survival of the child 
depends largely on the vigor and appropriateness of 
the treatment that is instituted. Finally, in some 
cases the children present no symptoms of active 
syphilis at first, but show in the course of time the 
well-known Hutchinsonian triad of signs: the inter- 
stitial keratitis, the purulent otitis, and the notched 
and peg-top-shaped incisor teeth. Epiphysitis, dac- 
tylitis, and other bone and visceral lesions occur later, 
with serpiginous ulcerative or rupial skin lesions. 
This last form, in which so-called tertiary lesions oc- 
cur later in life without the appearance of the earlier 
ones, is the syphilis hereditaria tarda, and can with dif- 
ficulty be distinguished from the acquired form of the 
disease. Wolff has recorded a case occurring at the age 

of thirty-four years, and still later ones have been noted. 

. Fig. i io. — Alopecia syphilitica. 

The skin eruptions of the hereditary luetic disease After Lesser. 



Fig. 109. — Paronychia syphilitica. 

From photograph by the author. 




INFLAMMATIONS. 203 

are similar in a general way to those of the acquired variety. They appear in 
almost all cases within three months of birth, and are rare after the sixth month. 
They may be erythematous, papular, pustular, or gummato- ulcerative in character. 
The erythematous hereditary syphiloderm is rather uncommon, appearing in the first 
days of extra-uterine life. The face, especially around the mouth, the sides of the 
abdomen, and the palms and soles are reddened diffusely or in spots. The exanthem 
is sometimes a. precursor of other forms of eruption. The papular hereditary syphilo- 
derm is by far the commonest form of the disease. It appears as large, red or copper- 
colored, slightly elevated, shiny papules ; at the folds of the skin they sometimes 
become hypertrophic (condylomata lata), but they are more liable in the delicate 
infantile skin to become eroded ; on the mucous membranes they appear as mucous 
patches; on the palms and soles the eruption is often slightly scaly. The pustular 
form of the hereditary syphiloderm is known as pemphigus syphiliticus neonatorum, 
and, while commoner than the same form in the acquired variety of the disease, is 
much rarer than the papular eruption. It appears at birth or a few days after, and is 
most marked on the palms and soles ; the lower extremities are frequently affected, 
but the face and trunk are seldom involved. The bullae are flat, pea to hazelnut in 
size, with contents of clear fluid or cloudy or greenish pus. Destruction of the 
derma occurs underneath, and scars result if the child survives. Syphiloderma 
hereditaria gummatosa-ulcerosa is rare, and usually appears three months or more after 
birth ; softening and ulceration almost invariably occur. 

Onychia occurs in the hereditary disease both as a nutritive change and as an 
inflammation of the matrix. Alopecia is also seen, similar to that of the acquired 
form. 

Pathology. — Though the various dermal lesions of syphilis differ greatly from 
one another in external appearance, they are essentially alike in their microscopic 
structure. They are all granulomatous tumors, caused by the presence and growth 
in the tissues of an infective agent as yet unknown. Even in its macular form the 
microscope shows that the syphiloma consists of a dense, sharply limited infiltration 
of indeterminate small round cells, situated in the upper corium and papillary bodies 
in the earlier, and in the lower corium and subcutis in the later lesions. Around 
these masses are the results of inflammation, evidences of suppuration, caseation, 
fatty degeneration, etc. It is characteristic of these tumors that they are never 
capable of higher organization, but always undergo fatty degeneration and absorp- 
tion, or ulcerative disintegration, or suppuration. In these retrograde changes the 
normal elements of the tissue invaded are also destroyed, and hence arise the atro- 
phies and cicatrices that are characteristic of the disease. The changes are always 
centrifugal, so that the peripheral portion of a lesion or of a series of lesions is a 
recently formed and growing infiltration, while the central and older portions are 
already far advanced in the retrogressive changes. Endarteritis is a common accom- 
paniment of the process and explains many of its features. In the hypertrophic form 



204 ILLUSTRATED SKIN DISEASES. 

of the syphiloma known as the condyloma there is considerable growth of the 
papilla itself in addition to the granulomatous infiltration ; and the gumma is a 
granuloma with a network of connective-tissue fibers ramifying through the mass. 




Fig. hi. — Multiple gummata. 

From photograph of one of the author's patients. 

Etiology. — The syphilodermata are caused by a virus that enters the system 
through an abrasion of the skin or mucosae in the acquired form, and that is trans- 
mitted through the blood in the hereditary variety of the disease. This inoculation, 
after leading to local inflammatory changes already considered under the heading of 
chancre, passes through the lymphatics and causes inflammation of first the neigh- 
boring and then the more distant lymphatic glands ; and finally, reaching the blood, 
causes the phenomena of the general disease, the symptoms of which appear on the 
skin and mucosae and in the internal organs. That the agent is organic in its nature 
is probable from the fact that this has been proved to be the case in many of the 
chronic infective granulomata — tuberculosis, leprosy, glanders, etc. — most closely 
related to syphilis in their pathological and clinical features ; and still more so because 
upon no other supposition can its enormous increase in quantity in the infected indi- 
vidual during the course of the disease be explained. Positive proof in this respect 
has so far been unattainable ; the various microorganisms found by Lustgarten, 
Doutrelepont, and others have not been seen by all observers, and both culture 
experiments and inoculations upon the lower animals have entirely failed. 

All the phenomena of the disease are explainable on the supposition that it is 
due to the presence of a microorganism and its toxins in the blood and the tissues. 
The chancre and the secondary eruptions are the direct product of the microbe, either 
alone or plus its toxins, while the tertiary lesions are due to the toxins deposited in 





SYPHILODERMA MACULOSUM. 



SYPHILODERMA GUMMATOSUM. 





TYPOGRAVURE. 



COPYRIGHT BY E. B. TREAT 4 CO., N. Y. 



GLOSSITIS SYPHILITICA. 



SYPHILODERMA PAPULOSUM 



PLATE XXXII. 



INFLAMMATIONS. 205 

the tissues and roused into activity by various causes; and the immunity from rein- 
fection is due to the presence of the toxins in the blood. The resisting power of 
the organism plays an important part in the growth of the virus ; tubercular and 
malarial subjects have severe forms of syphilis ; and parts irritated or inflamed from 
any cause are more prone to show the lesions of the disease than are others. 
Secondary infection with pyogenic organisms plays an important part in many mani- 
festations, more especially of the hereditary form. 

Not all the varieties of syphilis contain the virus in an active form, and from 
some lesions the disease cannot be produced in healthy individuals. In a general 
way all the moist and discharging lesions, both of the acquired and the hereditary 
form, are contagious; the sclerosis, the secondary papules and mucous patches, and 
the condylomata being eminently so. The blood-serum is not contagious, but the 
blood-corpuscles contain the virus. The physiological secretions — the milk, saliva, 
tears, etc. — cannot carry the contagion, save when contaminated with blood-glob- 
ules or the detritus of lesions ; and the same is true of ordinary pathological secretions. 
The lesions of tertiary syphilis do not contain the virus, but only its products, and 
are not contagious. 

The modes of transmission of the virus are extremely various. It can be gotten 
by direct contact, as in intercourse, kissing, vaginal examination, etc. ; or by medi- 
ate infection, the virus being deposited on some article, and then conveyed to the 
body of the recipient, as on a lead-pencil, tooth-brush, dental instrument, etc. ; or 
it can be transmitted with the semen or ovum to the fetus. In all cases but the 
latter a lesion of the skin or mucosa, however minute, is required to permit the virus 
to enter the system of the recipient. 

Diagnosis. — The protean lesions of the syphilodermata are often with difficulty 
distinguishable from those caused by other diseases ; and this has led to the use of 
such inapplicable terms as acne syphilitica, pemphigus syphilitica, varicella syphili- 
tica, etc. No single set of differentiations is, however, of greater importance in 
the whole field of medicine, since it is but too often not merely a question of accu- 
rate diagnosis and correct treatment, but one which involves the happiness, mental 
quietude, and domestic peace of many human beings. A discreet reticence 
should always be observed in the statements made to our patients, whatever our 
convictions as to the nature of the disease may be ; and concealment is in many 
cases an imperative duty. Nevertheless, our paramount concern is the cure of the 
disease, and if a plain statement of facts is necessary for that purpose, other con- 
siderations must be subordinated to it. 

Certain general considerations are in place before considering the diagnosis of 
the various syphilodermata in detail. First and foremost, the patient's history is 
hot only useless, but is positively misleading. Forgetfulness and inattention to the 
often trivial early manifestations of the disease, combined with the very natural dis- 
position to deny the facts, deprive it of all reliability. It should be inquired into, if 



206 ILLUSTRATED SKIN DISEASES. 

at all, only after the diagnosis has been made from the objective symptoms. Sec- 
ondly, in some doubtful cases we can employ the touchstone of treatment. Our 
means for the cure of syphilitic manifestations are so powerful and certain that the 
mere fact that a lesion is refractory to the ordinary treatment of the disease is prima 
facie evidence against its luetic nature. But the treatment must be vigorous and 
the dosage large, for many of the lesions, more especially of late syphilis, react only 
to energetic measures. Finally, the syphilodermata have certain general character- 
istics (p. 191); and a circular or crescentic arrangement, a copper-color, secondary 
ulceration or heaped-up crusts, the absence of subjective symptoms and the presence 
of characteristic symptoms or lesions elsewhere, of adenopathy, angina, cephalal- 
gia, alopecia, osteocopic pains, or the remains of the sclerosis, will often help us to 
reach a definite conclusion. 

Syphiloderma maculosa may be faintly marked, and is doubtless often over- 
looked; but it is not difficult to diagnose. The non-scaling, non-elevated, discrete 
spots, situated chiefly upon the trunk, are quite characteristic. Urticarias, and 
more especially the roseolous eruptions that sometimes follow the ingestion of drugs 
like copaiba, cubebs, quinine, etc. (roseola balsamica), have more or less well-marked 
wheals and itch greatly. The eruptive fevers, and more especially measles, may 
resemble it ; but the presence of the symptoms on the mucous membranes, together 
with the fever, will distinguish them. The eruption of typhoid fever consists usually 
of but a few spots, and is accompanied by the characteristic temperature curve. In 
erythema multiforme the spots are elevated, and are especially apt to appear on the 
backs of the hands and the flexor surfaces of the limbs. It would seem impossible 
to confound trichophytosis corporis, pityriasis rosea, or chromophytosis with the 
roseola of syphilis ; the discrete spots with fading centers and scaly margins of the 
first two, and the diffuse or circumscribed brownish discolorations of the third, should 
suffice to prevent error without resort to the microscope. The marbling of the skin 
apparent in some individuals when the body is exposed to cold air fades away as 
soon as the integument is warmed. 

The papular syphiloderm, large and small, may resemble a psoriasis very closely, 
both in appearance and in distribution. But the papules of syphilis are dark-red, 
dense infiltrations, and the scaling is central, and consists of dirty cast-off epi- 
thelium. In psoriasis the scales are shining, abundant, heaped up, and seated on 
bright-red non-infiltrated areas; scraping shows the bleeding points of the hyper- 
trophied papillae, and the seat of the lesions is mostly upon the extensor surfaces of 
the limbs. Acne is situated mostly upon the face, and is accompanied by come- 
dones ; its papules are short-lived, bright-red, acuminate, and often become pustules. 
In eczema the papules are not sharply limited and not infiltrated, and other forms 
of the disease, marked by moisture, vesiculation, crusting, and itching, are almost 
always present at the same time. The lesions of scrofuloderma are small, livid, red 
or skin-colored papules occurring in childhood in groups on the trunk and the ex- 



INFLAMMATIONS. 207 

tensor surfaces of the limbs, are very chronic, and are usually accompanied by glandu- 
lar swellings, mucous discharges, etc. 

On the palms and soles the papulo-squamous syphiloderm must be differentiated 
from eczema. This may be difficult ; but careful observation will reveal the dusky- 
red, infiltrated papules with semi-detached scales at their margins, and arranged 
often in groups, or a larger discolored area with a coppery, infiltrated wall. Eczema 
has no papules, and is more irregular ; the epidermis is thickened and cracked near the 
fingers; itching is present; and weeping or crusted surfaces extend into the clefts of 
the fingers or on to the surrounding skin. Psoriasis is almost unknown upon the palms 
and soles, and occurs as a diffuse scaling without infiltration ; and other distinctly psori- 
atic lesions will be found at the seats of election of that disease. The hypertrophic 
moist papule must be distinguished from the acuminate or simple condyloma. These 
latter are caused by the irritation of gonorrheal, chancroidal, or other discharges, 
and are distinctly warty, fissured, and pedunculated ; while the syphilitic lesions are 
broad, mushroom-like growths, and are almost always accompanied by the correla- 
tive forms of the efflorescence, dry papules or mucous patches. 

The pustular syphiloderm consists of more or less regularly grouped papules 
seated on infiltrated bases. It may resemble a variola so closely that an immediate 
diagnosis is impossible. There are the same stages, — papules, vesicles, and pus- 
tules, — followed by scarring; and high fever and marked general symptoms are 
sometimes present. The rapid and definite course of the smallpox lesion to its 
termination in eight to twelve days finally removes all doubt. In pustular acne we 
have the seat of the disease on the face and back, the absence of fever and other 
acute symptoms, and the presence of small acuminate papulo-pustules, situated on 
inflammatory bases, in various stages of development. In impetigo contagiosa 
there are flat pustules, drying up into yellow crusts, under which is a moist, non-infil- 
trated surface ; the disease occurs mostly in children. 

The tubercular syphiloderm may resemble lupus vulgaris, leprosy, epithelioma, 
or psoriasis. In lupus the numerous small, soft, deep-seated, apple-jelly-like nod- 
ules, appearing in early life and progressing very slowly, are peculiar. Leprosy has 
its characteristic history : the tubercles are large and form enormous nodular, var- 
nished-looking masses, growing very slowly ; and anesthetic areas are almost always 
present. Epithelioma usually develops from a wart, is most often single, occurs in 
the aged, and has prominent, hard, waxy edges with minute blood-vessels running 
over them. Finally, in a psoriasis, though it may closely resemble a tuberculo- 
squamous syphiloderm, the lesions are pinkish, abundantly covered with silvery 
scales, and there is never any loss of tissue. 

The gummatous syphiloderm is sometimes easily recognized, being present as a 
single one or only a few tumors ; it is hard, of large size, and sharply limited, ele- 
vated, and coppery or ham-colored; or appears as a kidney-shaped ulceration with 
hard, infiltrated, coppery margins. Its distinction from certain non-luetic affections 



208 ILLUSTRATED SKIN DISEASES. 

of the skin, more especially from certain tumors, is sometimes very difficult. So far 
as the non-ulcerated gumma is concerned, fibroma is harder and denser, and lipoma 
softer; and in both the continued absence of inflammatory symptoms will in time 
elucidate the diagnosis. Rhinoscleroma is marked by its location, its excessive and 
cartilaginous hardness, the extreme chronicity of its course, and the very rare occur- 
rence of ulceration. In sarcoma the tumors are numerous and pigmented, the 
cachexia that sets in is characteristic, and the general health is markedly involved. 
The softened gumma has often been mistaken for an abscess ; it may be distinguished 
from it by the chronicity of its course, and the absence of pain and active inflamma- 
tory symptoms. 

The exulcerated gumma may resemble a lupus so closely that a special term, 
lupus syphiliticus, is employed by some writers to designate this variety of the lu-. 
etic disease. Lupus, however, begins in childhood or in youth ; its nodules are small, 
numerous, yellowish brown in color, non-elevated, and soft, and their growth is 
very slow. If breaking down has occurred, the ulcers are elevated and filled with 
hypertrophic, easily bleeding granulations ; there is no continuous infiltrated margin ; 
characteristic papules are seen outside the ulceration, and also in the old scar tissue 
already traversed by the disease; and only exceptionally are the cartilages and 
bones involved. The ulcerative scrofuloderm may also be mistaken for a gumma ; 
but its edges are less hard, non-infiltrated, and lax and undermined; and the 
ulceration is most apt to occur on the neck and in children who exhibit evidences 
of disease of the lymphatic glands and the bones. In carcinoma, more especially in 
its epitheliomatous form, the ulcer has a red, easily bleeding base ; its margins are 
hard and waxy ; it grows very slowly ; and it is accompanied later by involvement of 
the lymphatic glands. Lupus erythematosus is a superficial inflammation with 
slightly elevated edges ; ulceration never occurs, and the scar is soft and superficial. 
Gumma of the genitals has been mistaken for a chancre, but the absence of the 
characteristic hardness, the non-appearance of secondary symptoms, and the pres- 
ence of evidences of past luetic disease should prevent mistake. 

The ulceration of syphilis requires to be differentiated from that which accom- 
panies other dermal affections, and more especially the common ones, lupus and 
simple dermatitis. It can be done with readiness if the nature of the syphilitic 
process is borne in mind. The specific ulceration always arises from the breaking 
down of the characteristic infiltration, which is a sharply limited, densely packed 
collection of small round cells in the corium. Each ulcer commences in the center 
of a papule, tubercle, or gumma, and spreads by peripheral extension of the infil- 
tration with central extension of the breaking down. A sharply limited and dense 
zone of infiltration therefore surrounds each such loss of tissue, the skin around it 
being entirely unaffected. The ulcer of dermatitis is more frankly inflammatory, 
and lacks the infiltrated wall around it ; it is shallower, has redder, softer, and more 
s\r ping edges, its margins are not sharply limited, and an extensive area of inflamed 




TTPOGRAVUF.F. 



COPYRIGHT BY E. B. TREAT 4 CO., N. Y. 



SYPHILODERMA Tuberculo— Ulcerosum. 



PLATE XXVIII. 



INFLAMMATIONS. 209 

skin surrounds it. The ulceration of lupus is extremely slow, begins in youth, is 
often covered with hypertrophic granulations, and shows at its margins the char- 
acteristic nodules of the disease. 

Prognosis. — The prognosis of the syphilodermata in general is good, though some 
are more resistant to antiluetic treatment than others. The macular are the easiest, 
and the pustular and ulcerative the most difficult, forms to cure. The general con- 
dition of the patient is of great importance, the prospects of cure being worse in 
broken-down, intemperate individuals, and in those debilitated by chronic or acute 
disease. The early appearance of late forms of gummatous lesions is of bad prog- 
nosis, as is also the rapid occurrence of relapses of the dermic lesions. The ulcera- 
tive and gummatous syphilodermata may themselves, if very extensive, determine 
a fatal ending to the disease. In hereditary syphilis the prognosis is doubtful. In 
all cases thorough and appropriate treatment is an important element in determin- 
ing the result. 

Treatment. — The treatment of the syphilodermata is that of constitutional syphi- 
lis, together with certain local measures. The systemic poison is in all cases the 
same, and the severity of its manifestations depends on the condition of the patient 
and the treatment to which he is subjected. Care of the general health is therefore 
of the utmost importance, and tonics, nourishing food, fresh air, bathing, exercise, 
and travel should be judiciously employed, so as to place the patient in the condition 
most favorable to resist the ravages of the disease. Special attention should be 
paid to the hygiene of the skin, since that is the organ most frequently attacked. 
The mucosae are hardly less liable to be involved ; and that of the buccal cavity is 
not only a frequent seat of characteristic lesions of the disease, but is of especial 
importance, because it is also liable to be injured by the drugs that are required in 
the treatment. In every case of syphilis, therefore, even before treatment is begun, 
the mouth should be carefully examined and all defects remedied ; the teeth should 
be put in good order, and an antiseptic mouth wash (No. 96, p. 209) should be regularly 
employed. If the gums are at all inflamed or spongy, an astringent lotion (No. 97, 
p. 209) may be used several times a day. 

No. 96. Antiseptic Mouth Wash. No. 97. Astringefit Mouth Wash. 

R Acid, carbolic. . . 1 part R Acid, tannic. ... 1 part 

Spts. vini Glycerini 

Aquae destil. . . . aa. 50 parts Aquae destil. . . . aa. 10 parts 

Mercury and iodine are the two drugs most useful in the treatment of the syphilo- 
dermata. Mercury is an antidote to the specific poison, and is of benefit in almost 
all the stages of the disease. Iodine causes the disappearance of the gummatous 
accumulations, but does not prevent their formation ; it is therefore most efficient 
for the later lesions. The treatment with mercury is to be commenced as soon 



210 



ILLUSTRATED SKIN DISEASES. 



as the diagnosis of syphilis is made. This, as we have already seen, cannot be done 
from the initial lesion alone, and premature treatment may prevent the appearance 
of the secondary symptoms, and leave us forever in doubt as to whether infection 
has taken place. The appearance of the general adenopathy, the angina, or the 
eruption is the signal that we must await. The dose of mercury then given should 
be as large a one as the patient can bear without the occurrence of salivation or 
gastro-intestinal disturbance. With the retrocession of the symptoms it may be 
diminished, and the patient should be kept steadily on the smaller dose for a num- 
ber of months. The reappearance of active symptoms on the skin and elsewhere is 
the signal for pushing the medication ; and even if that does not occur, two or three 
courses of active medication should be given during each of the first two or three 
years of the disease. During the second year, when the dermic symptoms become 
more localized, the iodine preparations, together with the mercury, give us the best 
results. After that, in the stage of the late lesions of which the gumma is the type, 
iodine is still more efficacious and must be given in larger dose ; but mercury in 
small amounts is always useful, and sometimes indispensable, to effect a cure. 



No. 98. Protiodide Pill. 

fy Hg. iodid. virid. 
Pulv. opii 
Extr. gent. 

F. pil. No. 60. 



3i 

gr. 10 
q.s. 



No. 99. Mixed Treatment. 



& 



Hg. chlor. corr. 
Kali iodidi . 
Syrp. zingiber 
Aquae . 



Dose 3i 



ad. 



gr- 1 

fss 

fii 



No. 100. Calomel Powders. 

$ Calomelani 
Sacch. alb. 

Div. in pulv. No. 10. 



No. JO J. Oleate of Mercury Ointment. 

gr. 1 I£ 01. hydrarg., 20-per-cent. solu- 

3ss tion ..... 1 part 

Petrolati ... .2 parts 



The most convenient method for the administration of mercury (see p. 48) is 
undoubtedly by the mouth, and it is the one preferred by most practitioners. It is 
slow, however, and uncertain, since we cannot know what proportion of the drug is 
absorbed by the digestive tract ; and it is liable to cause salivation and gastro-intes- 
tinal irritation. The protiodide is the most commonly used preparation, and it 
should be given in A- to 1 -grain doses, in accordance with its effect. The griping 
and diarrhea that it sometimes occasions may be obviated by combining a small 
dose of opium with it (No. 98, p. 210). The biniodide and bichloride are both irritat- 
ing, and are most frequently used in combination with the iodide of potash in the 
so-called " mixed treatment " suitable to the late secondary stages of the disease 
(Xo. 99, p. 210). The tannate is less irritating than most other preparations of the 
drug, but it is less effective than the protiodide and must be given in larger doses. 




COPYRIOHT BY E. B. TREAT 4 CO., N. Y. 



PHOTOGRAVURE AND COLOR CO., N. Y. 



GUMMA SUBCUTANEUM 



PLATE XXX. 



is especially efi' 
■ iren in r 
limes claih , or in 
The percutaneous o 
with many- syphiiographers; it 

when destructive pr 
by its use the gastro-intestina 
patients object to it; and it i 

Mercurial ointment 
oughly rubbed for fifteen minm 
to allow as long a val as possibi : 

rubbed. The loins, insides of the 
be avoided, as a troublesoi le folli< 
employed in very hirsute individ 
and may be used in the same 
reliable, and it is not so efficii 

mnction (No. 102, p. 212). 
Mercurial plaster applied to the trunk 
situ for several days, is u 
infantile skin, and there is n< 
mercurial ointment reduced by 2 or 3 p 
should be rubbed into the skin of the abd 
spread upon a cloth ana 
a rapid effect is de:- : : 
they must b^ given in a 
of one of ordinary siz< 
patients should rem:: 
The method that I 

em when prompt and \ 
rather intramuscular injection. 

disabilit advantages 

effic ill, it ne 

dance of the physician. The 
very rare when antiseptic pi 
serious results therefrom 
tion is scrubbed with soap and 
then with ether. The neec 
flame immediately before 
immediately upc 
deep into the musc'h 
than the ordinary 



a 




JBCIITA' 



INFLAMMATIONS. 211 

Calomel is especially efficacious in the hereditary and acquired syphilis of children; 
it may be given in powder (No. ioo, p. 210), or as tablets in doses of yo of a grain 
two to four times daily, or in the form of half-grain doses of gray powder. 

The percutaneous or inunction method of mercurial medication is a favorite one 
with many syphilographers ; it is efficient and rapid enough to be preferred to inges- 
tion when destructive processes are in progress or important organs are threatened ; 
by its use the gastro-intestinal tract is entirely spared. It is troublesome and dirty ; 
patients object to it ; and it is very liable to cause eczematous eruptions in sensitive 
skins. Mercurial ointment is the favorite preparation; ^ to 1 dram should be thor- 
oughly rubbed for fifteen minutes every night on a different part of the body, so as 
to allow as long an interval as possible to elapse before returning to the part first 
rubbed. The loins, insides of the thighs, etc., should be selected; hairy parts must 
be avoided, as a troublesome folliculitis is liable to occur, and the method cannot be 
employed in very hirsute individuals. Mercurial soap is cleaner than the ointment, 
and may be used in the same way ; but the commercial preparations are not very 
reliable, and it is not so efficient. The oleate of mercury is an eligible preparation 
for inunction (No. 102, p. 212). 

Mercurial plaster applied to the trunk and extremities, and allowed to remain in 
situ for several days, is useful, especially in children. Absorption is rapid in the 
infantile skin, and there is no better way of treating hereditary syphilis than by 
mercurial ointment reduced by 2 or 3 parts of an excipient. A bean-sized piece 
should be rubbed into the skin of the abdomen daily, and a small additional quantity 
spread upon a cloth and placed next to the skin under the child's belly-band if 
a rapid effect is desired. In the same class of cases the sublimate baths are useful ; 
they must be given in a wooden wash-tub, 5 to 30 grains being used to the contents 
of one of ordinary size. Adults can take from 75 to 150 grains to the bath; the 
patients should remain immersed therein for from twenty minutes to an hour. 

The method that I prefer, however, for the introduction of mercury into the 
system when prompt and vigorous action is required, is that by subcutaneous or 
rather intramuscular injection. Its disadvantages are a moderate amount of pain 
and disability ; its advantages are cleanliness, exactitude in dosage, rapidity and 
efficiency, and, above all, it necessarily keeps the patient under the care and gui- 
dance of the physician. The painful infiltrations and abscesses formerly noticed are 
very rare when antiseptic precautions are employed, and I have never seen the 
serious results therefrom that have been recorded. The skin at the site of the injec- 
tion is scrubbed with soap and water, and with 1 : IOOO corrosive chloride solution, and 
then with ether. The needle is kept in carbolized oil, and is passed through the 
flame immediately before the puncture; and this latter is closed with rubber plaster 
immediately upon the withdrawal of the instrument. The injection should be made 
deep into the muscles of the buttock or back, a needle somewhat longer and coarser 
than the ordinary hypodermic one being employed. 



212 ILLUSTRATED SKIN DISEASES. 

Either the insoluble salts first used by Scarenzio in 1864, or the soluble ones 
introduced by Lewin in 1867, may be employed. The soluble salts act most 
quickly, but only a small quantity can be introduced at a time, and the injections 
must be repeated daily or every other day. The most commonly used is the subli- 
mate (No. 102, p. 212) in i-per-cent. solution, of which 10 minims may be injected 
at a dose. Twenty to thirty such injections form a course, according to the neces- 
sities of the case. The albuminate, peptonate, and many other soluble preparations 
have been recommended, but they do not seem to possess any advantages over the 
corrosive chloride. 

The insoluble salts cause moderate pain ; deep infiltrations sometimes occur, 
but abscess formation is rare. The injection needs to be repeated only once in five 
to fourteen days, the mercurial deposited in the tissues being slowly transformed 
into a soluble salt and absorbed. Eight to ten injections form the usual course. 
Calomel in 10-per-cent. suspension in liquid vaseline (No. 9, p. 46) is most often 
employed, the dose being from 3 to 10 minims. The salicylate of mercury may be 
used in the same way (No. 103, p. 212) ; it is less painful than calomel, and less liable 
to salivate. The so-called gray oil, highly recommended by Lang, is a form of 
mercury in oily suspension (No. 104, p. 212), and should be slightly warmed before 
using. 

No. J02. Sublimate Injection. No. J03. Salicylate-of-mercury Suspension. 

R Hydrarg. chlor. corr. . . 1 part R Hydrarg. salicyl. 1 part 

Sod. chlorid. . . .10 parts Petrol, liquid. . . .10 parts 

Aq. destil. . 



1 part R 
10 parts 


Hydrarg. salicyl, 
Petrol, liquid. 


. 100 " 




No. J04. Gray 


Oil. 


R Hydrargyri 
Adip. lanae 
Petrol, liquid. 


. aa. 3 parts 
4 " 



In the ordinary syphilodermata, which may be regarded as part of the regular 
symptomatology of the disease, internal treatment is the easiest and is perhaps 
sufficiently reliable. But in obstinate cases, and especially where the irritability of 
the gastro-intestinal tract is too great to allow a sufficient quantity of the remedy to 
be absorbed, inunctions are to be preferred. Where the skin lesions are obstinate, 
numerous, and deep-seated, in the late ulcerative processes, and in cases where a 
differential diagnosis between syphilis and malignant or tubercular disease must be 
speedily made, the hypodermatic method of administration should be employed. 

While mercury is no longer given in the doses that were once customary, and 
salivation is not now a necessary accompaniment of the treatment, the drug must 
frequently be pushed to the point of toleration, and slight stomatitis, swelling of the 
gums, and salivary flow are sometimes developed. The more serious forms of mer- 




COPYRIGHT, BY E. B. TREAT & CO., N. Y. 



PHOTOGRAVURE & COLOR CO., N. Y. 



RUPIA SYPHILITICA 



PLATE XXXI. 






very rai t 
Iodine is, next to m< 
mata, more espt 
most c aly used 

ometimes be employ 
best prescril> 
taken in a considers 
dary and early t< 
■ 

3 a day, but the on: 
tient and the effect 
especially in the very late l< 
in some cases. The 
stomach rebels, and the iodide in >n, an 

almost as efficient when 






No, 105. 

. [ ali s. nat. iod 



No. J07. 
fy Tra. iodinii 

: - 



Iodoform is sometimes 
as also 2 to 3 drop d< 

itated and anemic c 

Like mercur 

- i 






it 




PHIL 






INFLAMMATIONS. 213 

curial poisoning, with diarrheal and bloody discharges from the bowels, and albu- 
minuria, are very rarely seen to-day. 

Iodine is, next to mercury, our main reliance in the treatment of the syphiloder- 
mata, more especially in the later forms. The iodides of potassium and sodium are 
most commonly used ; the latter salt, being less of an irritant and cardiac depressant, 
can sometimes be employed when the former cannot. Being deliquescent, they are 
best prescribed in a saturated solution (No. 105, p. 213), and should invariably be 
taken in a considerable quantity of milk or water after eating. In the late secon- 
dary and early tertiary lesions they are often given in combination with mercury 
(No. 99, p. 210) ; but it is best to give them separately, as the relative doses can be 
more conveniently changed. The ordinary amount is from 15 to 60 grains three 
times a day, but the only limit to the dose administered is the tolerance of the pa- 
tient and the effect on the disease. Ordinary quantities are frequently inefficient, 
especially in the very late lesions; and 500 grains or more daily must be adminis- 
tered in some cases. The rectum may be called upon for assistance when the 
stomach rebels, and the iodide in solution, and well diluted with water and milk, is 
almost as efficient when given in this way as when administered by the mouth. 

No. J05. Iodide-of-potash Solution. No. 106. Iodoform Pills. 

R; Kali s. nat. iodidi fy Iodoformi 

Aq. dest. . . . . aa. 1 part Extract, glycyrrhizs . . aa. p. e. 

No. 107. Iodine Mixture. No. 108. Syrup of the Iodide of Iron. 

fy Tra. iodinii 1 part R Syrp. ferri iodidi . . .1 part 

Aq. dest 100 parts Syrp- simplicis . . .2 parts 

Iodoform is sometimes employed with good effect in 2-grain pills (No. 106, p. 213), 
as also 2 to 3 drop doses of the tincture of iodine in solution (No. 107, p. 213). In 
debilitated and anemic cases, more especially of children, the syrup of the iodide of 
iron is appropriate (No. 108, p. 213). 

Like mercury, iodine sometimes causes constitutional disturbance, and it is there- 
fore desirable to begin with a small dose and increase it gradually. The symptoms 
of iodism are coryza, catarrh of the pharyngeal and laryngeal tracts, gastritis, head- 
ache, redness of the face, and more especially acneform, furuncular, and nodular 
eruptions of the skin. 

Local treatment of the syphilodermata is not necessary when the symptoms are 
not extensive or threatening, but it is a powerful adjuvant to the internal method. 
When the general eruptions are situated on the skin of the face or hands, they are 
best treated by rubbing in the white precipitate ointment, either alone or with a 
small proportion of mercurial ointment, at night (No. 109, p. 214). In bad cases the 



214 ILLUSTRxVTED SKIN DISEASES. 

mercurial ointment or plaster, or the mercurial plaster-mull, may be applied to limited 
areas during the night. 

No. 109. Compound Mercurial Ointment. No. J JO. Mercurial Ointment and Pou<der. 

ft Ungt. hydrarg. ammon. ft Hydrarg. sozoiodol. . . i part 

Ungt. hydrarg. . . . aa. i part Amyli s. petrolati . . .20 parts 

No. UJ. Black Wash. No. JJ2. Sublimate Gargle. 

ft Calomel. ... 1 part ft Hydrarg. bichloridi . . 1 part 

Aq. calcis . . . ad. 100 parts Mel. ros. .... 1000 parts 

Aquae .... 4000 " 

No. 113. Permanganate Gargle. 

ft Kali permangan. . . 1 part 

Aquae .... 2500 parts 

The condylomata lata or moist papules should be first thoroughly cleansed with 
a 1 : 1000 sublimate solution ; or, if situated on the genitals, immersed in the sublimate 
sitz-bath (p. 211). They should then be washed with a saline solution and well 
sprinkled with calomel. The mercurial collemplastrum may be used in some cases. 
If the growths are very exuberant, they may be cautiously touched with a 5- to 
10-per-cent. sublimate alcohol, or nitric acid, or the acid nitrate of mercury, or pure 
carbolic acid ; but this will rarely be necessary. 

The palmar and plantar syphiloderms should be treated with local sublimate 
baths, followed by mercurial plaster. 

In the ulcerative affections, if there is not too much secretion, the mercurial plas- 
ter or collemplastrum or plaster-mull is very efficacious. Where there is crusting 
and suppuration, the crusts are to be removed by soaking with olive-oil or poultic- 
ing, the parts thoroughly cleansed, the ulcerated areas sprinkled with iodoform and 
covered with mercurial plaster. The sozoiodolate of mercury in 5-per-cent. powder 
or ointment (No. 1 10, p. 214) may be advantageously employed instead of the iodo- 
form. 

If the alopecia syphilitica requires treatment, frictions of 1 : 1000 sublimate solu- 
tion or of the ointment of ammoniated mercury may be employed. 

Paronychia and onychia are best treated with local sublimate baths, the affected 
parts being then carefully covered with mercurial plaster. 

For the mucous patches a I : 10000 or 5000 sublimate gargle (No. 1 12, p. 214) is 
useful, as is also the black wash (No. 1 1 1, p. 214). If they are very extensive, they 
may be sprayed once a day by the physician with a J-per-cent. sublimate ether, or 
touched with the nitrate-of-silver stick. 






I rili 




SYPHILODERMA ULCEROSUM. 




TYPOGRAVURE. 



COPYRIGHT BY E. B. TREAT i. CO. , N. 



CATHODE RAY DERMATITIS. 



PLATE XX. 



INFLAMMATIONS. 



215 



Gummata are never to be opened, no matter how marked the fluctuation may- 
be; resorption without the formation of scar tissue may occur even under these cir- 
cumstances. They should be kept covered with the collemplastrum or plaster-mull 
or the simple mercurial plaster. When ulceration has occurred, the treatment 
must consist in cleansing, sprinkling with iodoform, and covering with mercurial 
plaster. When the destructive process is rapid it is sometimes necessary to destroy 
the infiltrated advancing margin ; this may be effected by boring into it at various 
places with the nitrate-of-silver stick ; but I prefer to use the galvanocautery or the 
Paquelin. 

Mercurial stomatitis requires the immediate stoppage of all mercurial medication. 
A 5-per-cent. chlorate-of-potash solution must be freely employed as a mouth 
wash; permanganate of potash (No. 113, p. 214) is also useful. The ulcerations 
should be touched every two or three days with the nitrate-of-silver stick or with 
a 5-per-cent. chromic-acid solution. 






LEPRA. 

Synonyms. — Leprosy, elephantiasis Graecorum, lepra Arabum, Aussatz (Ger.), 
lepre (Fr.). 

Definition. — A chronic infectious disease, caused by the growth of the lepra 
bacilli in .the skin, mucosae, the connective tissue of the internal organs and periph- 
eral nerves, and manifesting itself on the skin by yellowish-brown macules or 
reddish and bronzed confluent tubercles, together with various paraesthesise and 
affections of the internal organs, and ending in death from internal complications or 
marasmus. 

Symptoms and Course. — Leprosy, so common in the civilized world up to the 
fifteenth century that laws regarding the marriage of lepers were made by Charle- 
magne, and that so small a country as England contained one hundred and twelve 
houses devoted to their care, had long been so infrequent that its existence had 
almost been forgotten when it was rediscovered by Daniellsen and Boeck early 
last century. It had, however, by no means disappeared. India, China, and Japan 
had been its main seat, but cases have always existed in the outlying districts of 
Europe, in Spain, Portugal, Italy, southern Russia, Norway, and the Baltic prov- 
inces. In the western hemisphere it is now found in Brazil, Guiana, the West Indies, 
and the Sandwich Islands ; and there are lepers among the Chinese of San Fran- 
cisco, the Norwegians of the Northwestern States, and the Creoles of Louisiana. 
Occasional cases are seen here, but they are all importations from countries where 
the disease prevails. 

Leprosy is a most chronic disease, lasting from five to twenty years before it 
reaches its fatal termination. Its onset is insidious, indefinite prodromal symptoms 
appearing for months or years before its definite outbreak. These consist of malaise, 



216 



ILLUSTRATED SKIN DISEASES. 



depression, lassitude, anorexia, diarrhea, and general gastro-intestinal disturbance, 
with occasional febrile attacks of a malarial type. Then comes the prodromal erup- 
tion, sometimes taking the form of lentil- to hand-sized, irregular, deep-seated 
infiltrations of a brownish-red color (lepra maculosa), and at others that of serous 
bullae, that leave ulcerated areas behind (pemphigus leprosus). After one or more 
of these eruptions there occurs an interval of some months or a year or two before 
the regular symptoms appear. These take two distinct forms, the tubercular and 
the anesthetic. 

Lepra tuberosa or tubercular leprosy is the commoner form of the disease, 
including 60 to 70 per cent, of all cases. After the prodromal macular stage above 

mentioned there appear on the body pea- to bean-sized, 
isolated, circumscribed, infiltrated spots, which finally be- 
come elevated into rounded tumors. They increase very 
slowly in size, and by coalescence finally form large nodu- 
lar masses. Their color is reddish brown, coppery, or 
bronze, and their surface is covered with a smooth and 
shining skin. They appear anywhere on the body, save 
on the scalp and glans penis ; but the face is always in- 
volved, and here they cause great and characteristic deform- 
ity. The nose and upper lip are swollen and infiltrated ; 
the lower lip and ears are thickened and stiffened ; the cheeks 
and forehead are occupied by large tuberous masses, and 
the whole face assumes a sullen, scowling expression (facies 
leonina). The trunk, the knees, and the dorsal surface of 
the hands are also markedly affected. Tubercles appear in 
the mucosae of the nose, mouth, and throat ; the tongue is 
infiltrated, swollen, and fissured; the voice becomes rough 
and toneless, and oedema of the glottis may occur ; and there 
is a peculiar sweet and sickly odor to the breath. The hair becomes dry and falls out. 
The nodules may be few or many ; they are frequently very painful, and always 
tender to pressure, so that motion of the parts is greatly interfered with. As they 
slowly grow in size and coalesce into larger tuberous masses, erysipelas- like attacks 
occur from time to time, marked with fever, diffuse reddening of the affected areas, 
and the appearance of new papules or the involvement of the internal organs. 
This was very noticeable in a case that I had under observation for a long time at 
Charity Hospital some years ago ; he had several severe attacks of this character 
each year, each one coincident with an increase of the tubercular eruption. 

After growing slowly for months and years, retrogressive changes finally set in. 
These may be interstitial in their nature, the mass gradually melting away, leaving 
dark, pigmented, atrophic areas behind. The cartilages and the bones may thus be 
destroyed without the appearance of ulceration. Usually, however, that process 




Fig. 112. — Lepra tuberosa. 

Case of Dr. S. Garciadiego, Guada 
lajara, Mexico. 



INFLAMMATIONS. 



217 




Fig. 113. — Lepra mutilans. 
After Joseph. 



finally sets in, probably occasioned by added exter- 
nal traumatisms, and flat, dry, and indolent leprous 
ulcers result. They lead to great destruction of tis- 
sue; the nose, fingers, toes, and even an entire limb, 
may be lost (lepra mutilans). The eyes may be de- 
stroyed by the breaking down of tubercles of the cor- 
nea and iris; oedema of the glottis may occur; and 
the facial deformity becomes a terrible one. Marked 
symptoms of mental deterioration set in, and the pa- 
tient finally dies from an intercurrent disease, — pneu- 
monia, phthisis, Bright's disease, etc., — from involve- 
ment of the internal organs or from general marasmus. 
The process is an extremely chronic one, frequently 
lasting for ten or more years. 

Lepra nervorum, anesthetic or macular leprosy, is 
commoner in the tropics, and is characterized by nerve 
lesions and subsequent trophic changes in the skin. 
After a preliminary period, marked by formication, 
pain, numbness, tenderness in various places, or gen- 
eral hyperaesthesia of the skin and shooting pains in 
the nerves, there occurs a gradual loss of sensibility and the power of motion in cer- 
tain parts. Then appear pale-yellow, circumscribed discolorations of varying size, 
which spread peripherically, with clearing centers, and coalescing into irregular areas. 
They finally become atrophic, preternaturally white, wrinkled, dry, and glazed, or 
covered with a fine desquamation. Complete anaesthesia finally sets in, either limited 
to the spots or extending over the entire body ; in consequence of which the patients 
suffer from traumatisms, ending in ulcerative processes that form the mutilating 
variety of the disease described above. Bullae occasionally appear, leaving anesthetic 
areas behind. Atrophy and contraction of the muscles go hand in hand with the 
other trophic processes. The hands become clawed, there is wrist-drop, the face is 
deformed, the eyelids and mouth cannot be closed, and the tears and saliva flow 
away. The nails become dark and fall off; the hair loses its luster and falls out. 
Painful swellings appear along the course of the peripheral nerves. The patient's 
strength gradually decreases ; ulcerative, pyemic, and erysipeloid complications set 
in; the intellect is dulled; and death occurs from diarrhea, Bright's disease, phthisis, 
or general marasmus. The malady is even slower than the tubercular form, lasting 
from fifteen to twenty years. 

Etiology. — The cause of leprosy is the presence and growth of the specific micro- 
organism, the Bacillus leprce, in the tissues. First discovered by Hanson in 1880, it 
has been found in all the various lesions of the disease. That it is transmitted 
by heredity is very questionable. It is undoubtedly contagious : Father Damien 



218 ILLUSTRATED SKIN DISEASES. 

acquired it after devoting himself for years to the care of the lepers on the Sandwich 
Islands, and Arning successfully inoculated a malefactor in Madeira. But its con- 
tagiousness differs from that of syphilis, tuberculosis, and the other infectious 
granulomata in that a very prolonged exposure is required. There is absolutely no 
danger from the disease under ordinary conditions. Lepers lived for years in the 
dermatological wards of the Charity Hospital of New York without communicating 
the disease. As is the case with syphilis, all attempts to inoculate it on animals 
have failed. 

Pathology. — The lesion of leprosy is a granuloma like that of syphilis and 
tuberculosis, a round-cell infiltration containing the bacilli and caused by their pres- 
ence. It is found in the corium of the skin, in the mucosae, the lymphatic glands, 
kidneys, liver, and other internal organs, and along the course of the peripheral nerves. 
The bacilli are readily demonstrated in sections of the tubercles ; they are rod-shaped 
organisms about half the size of a red blood-corpuscle, and are often contained 
in large cells, the so-called lepra cells. A slight cellular infiltration gives us the 
macular form of the disease, and a larger accumulation the tubercular. In the nerve- 
sheaths the bacillus causes a connective-tissue new growth with subsequent degen- 
eration of the nerve-fibers, an ascending neuritis, and, finally, disease of the central 
organs. The skin or mucous membrane lesions are always primary, though we do 
not know the point at which the virus enters the system. 

Diagnosis. — Lepra rarely or never occurs in individuals who have not resided in 
regions where it is endemic, a point of great value in its earlier and less characteristic 
stages. When fully developed, whether tubercular, anesthetic, mutilating, or mixed, it 
can hardly be mistaken for any other disease. The tubercular or tuberculo-ulcerative 
syphiloderm runs a much more rapid course, and soon undergoes absorption or 
ulceration ; there are no disturbances of sensibility ; the characteristic location and 
symmetry of lepra are absent ; other symptoms of syphilis are present, and the reac- 
tion to antiluetic treatment is marked. Syringomyelia causes deformities of the 
extremities similar to those of leprosy, but anaesthesia is always absent. Lupus is 
not so symmetrical, nor are its tubercles so large and varnished. Sarcoma cutis is 
more generally distributed : it has a quicker course and is rapidly fatal. Morphea 
and vitiligo show neither hyperaesthesia nor anaesthesia, and are not accompanied 
by constitutional symptoms. 

Prognosis. — This is entirely- bad ; the malady is slow, but invariably ends 
fatally. 

Treatment. — Prophylaxis consists in forbidding the intimate contact of leprous 
with healthy people; but strict isolation, and the barbarous methods too frequently 
employed to effect it, are entirely unnecessary. Remedial treatment can only be 
palliative, since all the various remedies that have been recommended have had no 
effect on the disease. Of these the chief are gurjun balsam, in doses of 75 to 150 



INFLAMMATIONS. 219 

grains daily; chaulmugra oil externally, and internally in doses of 3 drops to 1 
dram thrice daily ; ichthyol and resorcin, internally and externally. Each has had 
its advocates, but none has stood the test. A change to a climate where the disease 
is not endemic has a good effect in many cases ; but it must not be forgotten that 
the malady frequently remains stationary for long periods of time. 



MYCOSIS FUNGOIDES. 

Synonyms. — Granuloma fungoides, eczema tuberculatum, lymphadenie cutanee 
(Fr.). 

Definition. — A chronic infectious disease of the skin, caused by the growth 
therein of an as yet unrecognized microorganism, and characterized by the 
appearance of one or more firm, reddish, fungating tumors, together with various 
secondary dermal phenomena, and terminating in death from marasmus or 
complications. 

Symptoms and Course. — This rare disease is regarded by some authorities as a 
variety of sarcoma, and by others as a lymphadenoma of the skin ; but it is certainly 
a true infective granuloma. Two distinct stages are usually observed, but in some 
cases the first one is absent or passes unnoticed. This is the stadium praemy- 
coticum, in which the symptoms are often indefinite and closely resemble those of 
other more common skin diseases. Pruritus, either local or general, is very marked, 
and with it there occur eczematous, erythematous, psoriatic, and urticarial lesions 
on the skin of the trunk and extremities. The excoriations from scratching still 
further diversify the picture, and in this stage the malady may remain for months 
and years. Then there appear flat, irregular or curved, reddish or livid, and itchy 
infiltrations, which may remain dry or become covered with secretion or scales. 
This leads to the second, more characteristic stage, the stadium mycoticum. The 
circumscribed infiltrations, bean- to hand-sized or larger, develop into broad or 
pedunculated papillary tumors. Their color is pinkish or brownish red, or darker; 
there may be few or many ; and their papillary and rugose surface may be dry and 
covered with epithelium, or crusted, or excoriated and secreting. In the latter case 
a fetid fluid exudes from the tumors and renders the patient an object of disgust to 
himself and others. Any part of the body may be affected, but the face and neck 
are especially apt to be involved. The tumors occasionally disappear by resorption, 
leaving pigmented areas behind ; but new ones continually arise in their place. 
Enlargement of the lymphatic glandular system now becomes a prominent symptom. 
The general health finally suffers, diarrhea sets in, and the patient dies of exhaus- 
tion or intercurrent disease. The malady occurs at all ages, but is most often 



220 ILLUSTRATED SKIN DISEASES. 

seen after the fortieth year, and, with the exception of isolated instances in which 
the first stage is absent, takes a number of years — ten to fifteen — to run its 
course. 

Etiology. — The exact cause of the disease is unknown, the pathogenic microbe 
not having yet been isolated. 

Pathology. — The process consists of the development of a granulation tumor in 
the corium, which does not differ essentially from that of the other infective diseases 
of this class. 

Diagnosis. — The persistent and violent itching, with the scratch effects, lasting 
for years, and the appearance and retrogression of the eczema-like infiltrations, are 
our only diagnostic criteria in the early stages of the disease. These are often not 
sufficiently characteristic to permit a diagnosis to be made. The indolent papillary 
tumors of a fully developed case render the diagnosis more easy. Syphilis has no 
itching, has copper-colored infiltrations, and reacts to antiluetic treatment. Cutane- 
ous gummata tend to early purulent degeneration, which only occurs exceptionally 
in the latest stages of mycosis fungoides, more especially after irritation. Lepra has 
the anaesthesia and other nervous symptoms, the bullae, and the mutilations ; it does 
not occur here, and the characteristic bacilli can be readily demonstrated. Lupus 
vulgaris has a rapid involution, and the occurrence of ulceration and scarring is 
characteristic. 

Prog-nosis. — This is generally unfavorable, more especially in the later stages. 
Intercurrent erysipelas has cured one case, and Kobner and Marianelli have each 
reported a cure under arsenic. The earlier the diagnosis is made the better the out- 
look. 

No. JJ4. Arsenic Solution. No. H5. Sodium Arseniate Solution. 

R: Sol. Fowleri fy Natr. arseniosi . . . . gr. 5 

Aq. cinnamom. . . . aa. p. e. Aq. dest. ..... |i 

Sig. Gtt. 6 to 20 t. d. in water after meals. m. 1 = T ^o grain. 

No. JJ6. Camphor- Naphthol. 

V>L /3-naphthol 1 part 

Camphor pulv. . . .2 parts 

Treatment. — The treatment of mycosis fungoides is not to be regarded as hope- 
less, in view of the successes noted above. Arsenic must be given, either inter- 
nally as Asiatic pill (No. 6, p. 46) or Fowler's solution (No. 114, p. 220), or, better, 
by the hypodermic administration of sodium arseniate (No. 115, p. 220), one half to 
one syringeful being injected daily into the skin of the back. Naphthol, prefer- 
ably combined with camphor (No. 116, p. 220), the 10-per-cent. pyrogallol ointment 
(No. 93, p. 181), and the 10- to 20-per-cent. resorcin ointment (No. 20, p. 64) are 
recommended as local applications. 



INFLAMMATIONS. 



221 



LUPUS ERYTHEMATOSUS. 

Synonyms. — Seborrhea congestiva, lupus seborrheicus s. sebaceus, ulerythema 
centrifugum. 

Definition. — A small-celled new growth of the skin, appearing as various-sized 
reddish patches covered with grayish-yellow fatty and adherent scales, ending in 
interstitial atrophy and cicatrix formation, and sometimes accompanied by general 
symptoms and terminating in death. 

Symptoms and Course. — When Cazenave gave this malady its name in 185 i his 
selection was not a happy one ; for there is no relationship between lupus vulgaris, 
which is a tubercular granuloma, 
and this circumscribed erythema 
of unknown origin associated with 
seborrhea and ending in interstitial 
atrophy. Hebra, in fact, described 
it as a congestive seborrhea, and in 
some of its manifestations it is ap- 
parently closely related to atrophic 
rosacea. It begins with one or 
more primary efflorescences con- 
sisting of reddish, pinhead- to pea- 
sized, slightly elevated, shining 
spots, with small adherent sebor- 
rheal scales in their centers. When 
these scales are lifted up one or more 
minute plugs are found projecting 
from their under surfaces, which 
have evidently fitted into the dilated 
ducts of the sebaceous glands, which 
are patulous and open. The spots 
grow slowly by peripheral exten- 
sion, adjacent lesions unite, and 
new ones appear at the margins 
until the disease is fully developed. 
Two distinct varieties occur, differ- 
ing from each other in form of invasion and subsequent course. 

The more usual form is that known as lupus erythematosus discoides, in which 
the primary lesions unite to form one or more sharply circumscribed efflorescences 
which spread slowly by peripheral extension and by the coalescence of new marginal 
papules. The advancing edges of the patch are broad, and somewhat elevated ; they 




Fig. 114. — Lupus erythematosus. 
Case of Dr. R. Abrahams. 






222 ILLUSTRATED SKIN DISEASES. 

end abruptly toward the sound skin, and slope gradually to the center of the patch. 
Their color is a vivid red, disappearing under pressure. The center of the patch 
sinks in and becomes atrophic, ajid finally there is formed a flat, smooth scar, often 
marked with tortuous and dilated vessels. Seborrheal scales are usually present : 
they are firmly attached, and on removal show the characteristic plugs projecting 
from their under surfaces. Comedones and sebaceous accumulations are common 
in the neighborhood of the lesions, and there is often a marked accumulation of pig- 
ment in the normal skin near the advancing infiltrated wall. In some few cases the 
inflammation and infiltration are slight, the margin of the patch is pale and but little 
elevated, and the scales absent ; but interstitial atrophy of the center of the diseased 
area always occurs and is a characteristic change. Where there are no sebaceous 
glands the scales and their plugs are not present ; thus on the palms the affected skin 
is dry and hard (lupus erythematosus corneus), or cedematous and inflamed. 

The fully developed lesion is rounded or discoid in shape, though it may be 
gyrate when adjacent areas have united. Its seat is oftenest on the nose and neigh- 
boring parts, appearing as two symmetrical lateral masses, one on each cheek, with a 
smaller central connecting portion occupying the bridge of the nose (butterfly lupus). 
The scalp is frequently affected, and here the atrophic process leads to permanent loss 
of hair. The lips, eyelids, and ears are not uncommonly symmetrically involved, 
but the affection is rare upon the trunk. 

The course of lupus erythematosus discoides is exceedingly slow, lasting many 
years. It may remain apparently stationary for long periods of time. Pallor of 
the margin shows cessation of the peripheral cell growth, and when cure has taken 
place a thin, shining, and very superficial scar is left behind. The disease is seen 
oftenest in women from twenty to forty years of age. Spontaneous ulceration never 
occurs, and there are no subjective symptoms and no disturbance of the general 
health ; but the deformity that is entailed is serious. 

Lupus erythematosus disseminatus s. aggregatus is a very much rarer form of 
the disease, and, though the primary efflorescences are similar to those of the dis- 
coid form, it runs a very different course and shows all the symptoms of an acute or 
subacute infective disease. Its onset is accompanied by high fever, even up to 104 
F., with gastro-intestinal disturbance, pains in the limbs, and headache of marked 
severity ; with which are sometimes associated inflammatory effusions in the joints. 
The acuity of the invasion may be such that coma and death may occur therein ; 
even cases that recover from the first attack suffer from relapses and finally die, and 
the general mortality from this form of the malady reaches 50 per cent. The con- 
stitutional symptoms are accompanied by an eruption of the characteristic efflores- 
cences of the disease, which usually first appear on the face, but soon spread over 
the body ; they are often well-nigh universal, even the soles and palms being affected. 
It is characteristic of this form of the disease that, while the lesions are identical 
with those of the discoid variety, they do not spread peripherically ; the eruption 



INFLAMMATIONS. 



223 



comes out as a whole within a short time, and remains stationary. Retrogression of 
the general symptoms has no effect, however, on the dermal lesions. An intense, 
persistent, diffuse reddening of the face (erysipelas perstans faciei) frequently results 
from the acute attacks, and 
in the worst cases an erup- 
tion of clear or hemorrha- 
gic bullae accompanies the 
process. 

Etiology. — The cause 
of lupus erythematosus 
is unknown, but it is 
undoubtedly a bacillary 
infectious disease. The 
French authorities regard 
it as a tuberculosis, but 
this can hardly be the case, 
since tubercle bacilli have 
not been found, and in- 
oculation experiments on 
the lower animals have not 
succeeded. Seborrhea, ro- 
sacea, and erysipelas seem 
to predispose to its occur- 
rence. Many cases begin 
as a congestive seborrhea, 
the symptoms of which 
frequently remain present 
throughout the disease; so 
that there is ground for 
the assumption of a rela- 
tionship between the pro- 
cesses. 

Pathology. — The disease process is a chronic inflammation of the cutis, leading 
to degeneration, and ending in atrophy. The entire tissue or a part of it is infil- 
trated with an accumulation of small round cells, often appearing first in the neigh- 
borhood of the vessels; and the sebaceous glands are always involved and hyperse- 
creting. The new cells finally undergo fatty degeneration ; the glandular structures 
atrophy ; the hairs fall out ; and a new connective tissue, which undergoes cicatricial 
contraction, replaces the destroyed elements. 

Diagnosis. — The broad, somewhat elevated margins of the patch ; the seborrheal 
scales with processes from their under surfaces dipping into the dilated mouths of 




Fig. 115. — Lupus erythematosus. 
Case of Dr. R. Abrahams. 



224 ILLUSTRATED SKIN DISEASES. 

the glands; the central and very superficial scarring; and the extreme chronicity 
of the process, are characteristic of lupus erythematosus. Lupus vulgaris has its 
peculiar brownish-red, soft, deep-seated papules, and usually ulcerates ; the carti- 
lages are involved ; the malady begins in youth ; and the seborrheal scales and plugs 
are entirely absent. A rosacea is found in the location that is the favorite seat of 
lupus erythematosus ; but the dilated vessels, the acne pustules, the absence of sharp 
limitation and of scarring will serve to distinguish it. Chronic eczema of the im- 
petiginous or squamous form shows moisture, papules, vesicles, and crusts ; it is not 
sharply limited and is never followed by scarring. Trichophytosis is rapid in its 
course, has no infiltrated margin, has a paler center, shows readily detachable 
scales, is accompanied by itching, and the nibbled-off hairs are characteristic when 
the scalp is affected. A non-ulcerated serpiginous syphiloderm may resemble lupus 
erythematosus ; but the marked infiltration, the coppery color, the absence of sebor- 
rheal scales, with the presence of other luetic symptoms will serve to distinguish it. 
It seems impossible that psoriasis, with its shining scales and bleeding points, its 
characteristic seat, and the absence of scarring and loss of hair, should be mistaken 
for the disease. 

Prognosis. — The general health is not affected in lupus erythematosus of the dis- 
coid variety, but the prognosis as to cure is always doubtful. Some cases recover 
even without treatment, while others are most obstinate. In all cases some scarring 
results. The aggregate form is more serious ; acute exacerbations, with inflamma- 
tions of the thoracic organs, not infrequently occur, and lead to a fatal termination. 

Treatment. — Phosphorus has been recommended by Bulkley ; and anemia, 
chlorosis, and other general conditions that may be present must be appropriately 
treated ; but internal medication is of little use in the disease. In the local treat- 
ment we must always remember that recovery with a very superficial scar is the 
rule, and that destructive measures are to be employed only when the milder ones 
fail. No certain rules can be laid down ; some cases are very sensitive and will bear 
only the mildest ointments. The following method has been useful to me. After 
'the removal of the seborrheal scales with soap and water, green soap, preferably in 
the form of the tincture (No. 5, p. 43), should be rubbed into the patch daily, fol- 
lowed by the permanent application of mercurial ointment or plaster, or plaster- 
mull. Duhring recommends the sulphur ointment (Nos. 24, 25, p. 64), and 
naphthol (No. 48, p. 105, No. 124, p. 243) does well in some cases. Ichthyol in 
10- to 20-per-cent. strength as salve, paste, plaster, solution, or varnish (No. 72, 
p. 137, No. 85, p. 165, No. 87, p. 169), or the ichthyol- mercury salve (No. 53, 
p. 113), are somewhat more irritant but efficacious applications. The 10-per-cent. 
pyrogallol salve (No. 44, p. 100, No. 93, p. 181) may also be tried; and in cases that 
can bear it the cade-sulphur-green soap ointment (No. 117, p. 225) is a good appli- 
cation. 

Obstinate cases may resist all these measures, and we must have recourse to 




CHRONIC ECZEMA WITH LICHENIFICATION. 



W ^V^^w 






§ 1 


/ W f 


4? 

t. 




TYPOGRAVURE. 



COPYRIGHT, 1902. BY E. B. TREAT A CO., N. Y. 



RHINOSCLEROMA. 



CHROMOPHYTOSIS OF FACE - . 



PLATE LIV. 



INFLAMMATIONS. 225 

the more active agents. Iodized glycerin (No. 119, p. 225) may be applied to the 
part once daily, or lactic acid (No. 1 18, p. 225) as recommended by Joseph may be 
similarly employed. Some cases require the use of the stronger acids — trichlora- 
cetic, chromic, nitric, or even sulphuric acid being cautiously applied by means of a 
glass rod, followed by the use of a soothing ointment. A solution of caustic pot- 
ash, 1 part to 2 or 4 of water, may be used every fifth day or so, care being taken 
to prevent too deep an effect by the use of dilute acetic acid immediately afterward. 
The superficial use of the Paquelin cautery upon the margins of the patch, or " cross- 
hatching" it with the scarificator (Fig. 15, p. 50), followed by a dressing of pow- 
dered iodoform, has given good results in some cases. 

No. JJ7. Cade- Sulphur- Green Soap Ointment. No. JJ8. Lactic-acid Solution. 

fy 01. cadini g: Ac. lactici 

Sulph. lot. Aq. destil aa. p. e. 

Sapo. virid. . . . . aa. p. e. 

No. U9. Iodized Glycerin. 

R Iodin. pur. 

Kal. iodidi . . . aa. 1 part 

Glycerin .... 2 parts 

In the diffuse form of the malady local treatment is restricted to cold applica- 
tions, lead lotions, and the simple ointments (No. 17, p. 61, No. 26, p. 70, No. 29, 
p. 74, Nos. 68, 69, p. 135). Pallor and diminishing size of the infiltrated margin are 
the first signs of improvement in the patches ; and they are the signal for us to stop 
all more irritating measures and go back to green soap and mercurials, or even milder 
measures. 

RHINOSCLEROMA. 

Definition. — A chronic infectious granuloma affecting the skin of the nose and 
upper lip, and the nasal and pharyngeal mucosae, and characterized by the forma- 
tion of permanent, dense, contracting infiltrations. 

Symptoms and Course. — This very rare disease, first described by Hebra and 
Kaposi in 1870, begins as one or more nodular infiltrations in the nasal mucous 
membrane or in the skin around the anterior nares. At first isolated, they slowly 
increase in size, unite into larger tuberous masses, and spread forward on to the 
upper lip, the alae and the septum of the nose, as well as backward along the floor 
of the nostril on to the velum, pharynx, soft palate, epiglottis, and even the larynx. 
Their consistency is peculiarly hard and dense, resembling ivory to the touch ; the 
skin and mucosa covering them are immovable, and their glandular structures are 



226 ILLUSTRATED SKIN DISEASES. 

destroyed. Around the anterior nares the tumors form rounded or oval masses 
covered with a smooth, brownish-red or pale skin, in which neither hair-follicles nor 
sebaceous glands are to be found. Here they occasion a characteristic deformity, 
the nose and upper lip being greatly indurated and thickened, and all the structures 
flattened, as it were, upon the face. Slight superficial excoriations of the skin over 
the tumors are sometimes seen, but otherwise they are not subject to any retrogres- 
sive changes ; once formed, they are permanent. 

The affection is a very chronic one, often lasting for from ten to twenty years, 
and has been most commonly seen between the ages of twenty and thirty. It in- 
terferes in no way with the general health ; but the obstruction of the anterior nares 
finally prevents nasal respiration, and the extension of the process into the fauces, 
epiglottis, and larynx so interferes with respiration that the patients die therefrom 
or from intercurrent chest disease. 

Etiology. — The cause of the disease is the bacillus described by Frisch, Cornil, 
Alvarez, and others. It is an elongated, rod-shaped organism enveloped in an oval 
capsule, and closely resembles the pneumococcus in appearance. It is found among 
the connective-tissue fibers of the part, in the lymphatic vessels, and in the peculiar 
large cells. 

Pathology. — The small- celled infiltration in the corium does not differ from that 
of the other granulomata in its early stages, but it rapidly develops into a firm con- 
nective tissue, and even into cartilaginous and bone-tissue. Characteristic giant 
cells have been described by Mikulicz, and the bacilli mentioned above are always 
present. 

Diagnosis. — The seat of the tumors, their ivory hardness, the smooth skin cover- 
ing them, the absence of any retrogressive changes, and the extreme chronicity of 
the disease, are characteristic. Rhinophyma is a soft, doughy, lobulated tumor of 
the nose, with enlargement of the sebaceous glands and increase of their secretion, 
and follows long-standing rosacea. Keloid is rare on the nose, but some of the 
harder forms might resemble rhinoscleroma closely. Microscopic examination of an 
excised fragment will, however, show it to be composed of ordinary connective tis- 
sue, and no bacilli will be found. A syphiloderma is very much less dense, ulcer- 
ates or undergoes other retrogressive changes, and has a much more rapid course. 

Prognosis. — This is essentially bad ; the growth of the tumor is steady, though 
slow, and it finally destroys life by its interference with respiration. There is little 
to be hoped for from treatment, even as regards temporary relief from the deformity 
and disability. 

Treatment. — Interference should be postponed so long as the patient is not seri- 
ously inconvenienced by the growth. Complete excision is impossible, on account 
of its location, and partial removal is always followed by renewed growth. At- 
tempts may be made to keep the nostrils open by means of tents, metallic or glass 
tubes, or by the excision of portions of the mass. Temporary good results have 



INFLAMMATIONS. 227 

been reported from the use of i-per-cent. sublimate (No. 43, p. 100), and salicylic- 
acid ointments or pastes (No. 125, p. 243), combined with the internal administra- 
tion of the latter drug. 

ACTINOMYCOSIS. 

Actinomycosis is very rare as a primary disease of the skin, usually occurring 
secondarily to actinomycosis of the jaw, to which the ray parasite, the cause of the 
disease, obtains access through a carious tooth. It appears as one or more deep, 
subcutaneous, livid nodules, situated most commonly around the jaw or on the neck, 
which spread, undermine the skin, break down, and finally give vent to a purulent 
or sanguineous fluid. In this are pinhead- to pea-sized sulphur-yellow bodies, 
which the microscope shows to be composed of masses of the ray-shaped fungus. 
The malady is very slow in its course ; it was formerly supposed to always termi- 
nate fatally from marasmus caused by the long-continued suppuration, or from me- 
tastasis to the internal organs ; but the prognosis is now regarded as more favorable, 
spontaneous recovery taking place in many cases, and others remaining stationary 
for years. The only treatment is the surgical one. The tumors may be laid open 
and scraped out ; fistulous tracts can be curetted, and the galvano or Paquelin 
cautery can be freely used. In many cases ordinary antiseptic dressings will suffice. 



3. INFLAMMATIONS OF THE GLANDS. 

Inflammation of the sweat-glands is of rare occurrence, and can be briefly dis- 
cussed. Inflammations of the sebaceous glands are among the most frequent of 
dermal affections, including acne, rosacea, and folliculitis. 



HYDRADENITIS. 

Hydradenitis, an inflammatory affection of the sweat-glands, appears as circum- 
scribed, firm, hard, deep-seated nodules, from pinhead- to pea-size, from the upper 
surface of which a hard cord, the inflamed duct, can be felt passing to the surface. 
It is a rare affection, its most usual seat being the face, the genitocrural fold, and 
the neighborhood of the anus. The inflammatory products usually undergo absorp- 
tion; more rarely, suppuration and perforation, followed by fistula formation, ensue. 
It occurs most often in persons affected with hyperidrosis, more especially when 
complicated with other inflammatory infections of the skin — eczema, ringworm, etc. 
The treatment is that appropriate to the hyperidrosis or other disease conditions that 
may be present. The mercurial-carbolic plaster-mull is a good local application, but 
if suppuration has set in incision is required. 



228 



ILLUSTRATED SKIN DISEASES. 



ACNE. 

Synonyms. — Acne vulgaris, Hautfinuc (Ger.), acne (Fr.). 

Definition. — A chronic inflammation of the sebaceous glands and their peri- 
glandular tissue, characterized by the appearance of multiple, firm, painful, reddish 
or violaceous papules or tubercles, and of pustules, on the face, back, and other 
portions of the body. 

Symptoms and Course. — This very common affection is most often seen in persons 
of dark complexion and with coarse, greasy skins, and is usually associated with 

seborrhea of the dry and 
oily varieties, and come- 
do. Sebaceous hyperse- 
cretion and plugging of 
the gland orifices are fol- 
lowed by a follicular and 
perifollicular inflamma- 
tion. The lesion begins 
as a minute, acuminate, 
hard, reddish papule, in 
the center of which there 
is usually a comedo (acne 
punctata). Increase of 
the inflammation leads to 
the formation of pea- 
sized or larger nodules 
and tubercles of a reddish 
or violaceous color (acne 
papulosa). The inspis- 
sated sebum is usually in- 
fected with pus organ- 
isms ; suppuration begins 
in the deeper portions, 
and though no pus may 
be visible, puncture or in- 
cision will reveal its presence. Finally the pus reaches the surface, and the lesion 
becomes an acuminate pustule seated on an infiltrated, inflamed base (acne pustulosa). 
As the inflammation subsides the pus desiccates into a crust, and when this falls off 
a small circular or elliptical scar is left behind, for in all but the most superficial lesions 
the corium is destroyed. Each separate papule and pustule runs an acute course 
and ends in a few days ; but the constant appearance of new ones prolongs the dis- 




FlG. 116. — Acne punctata. 
From photograph by the author. 




COPYRIGHT, BY E. B. TREAT & CO., N. Y. 



PHOTOGRAVURE 4 COLOR CO., N. Y. 



ACNE. 



PLATE XLI. 



ich may 

■ 
rata), and oc 
trations, and dermic ab 

while the irritation of 
covered with an oily seer 

The erupt i 
tion. It is found on 
where the sebaceous * 

and most active, li fl| 

elsewhere, and on the 

hich have no seb 
glands, it does not occur. 
seen in both sexes, 
moner in males than in fern; 
is a disease of eai 

;n the pei 
and the thirtieth 

[] spontaneoi 

Certa./ 

am to be d I 

iphica tli 

isorj 

depressed ci< 

■ 
Tubercular, anc j^H 

pat! 

- 

upon 

Acne varii 



INFLAMMATIONS. 



229 



ease, which may last for many years. The lesions appear irregularly, and all the 
various stages are usually present at one and the same time. 

Sometimes the amount of the inflammatory induration is very great (acne indu- 
rata), and occasionally adjacent nodules and pustules coalesce to form larger infil- 
trations, and dermic abscesses of varying size result. In the worst cases the skin is 
covered with scars and sown with inflammatory nodules, pustules, and comedones, 
while the irritation of the sebaceous glands causes the integuerrent to be constantly 
covered with an oily secretion of unpleasant odor (acne inveterata). 

The eruption of ordinary acne is symmetrical, though irregular in its distribu- 
tion. It is found on the forehead, cheeks, chin, and upon the back, the regions 
where the sebaceous glands are 
largest and most active. It is rare 
elsewhere, and on the palms and 
soles, which have no sebaceous 
glands, it does not occur. It is 
seen in both sexes, but is com- 
moner in males than in females. It 
is a disease of early youth, occur- 
ring between the period of puberty 
and the thirtieth ) T ear, and it usually 
gets well spontaneously when that 
age is past. 

Certain varieties of the disease 
remain to be described. In acne 
atrophica there is no pus formation ; 
interstitial absorption of the pro- 
ducts of inflammation occurs, and 
depressed cicatrices are formed. 
Acne hypertrophica is due to the 
not uncommon development of 
keloidal outgrowths from the scars. 
Tubercular, anemic, and marantic 
patients suffer from acne cachecti- 
corum, an obstinate affection, in 
which flat livid or violaceous pap- 
ules occur rather on the body than 

upon the face, and, though they do not suppurate frankly, leave deep cicatrices be- 
hind them. Acne varioliformis s. necrotica occurs on forehead, temples, scalp, and 
the nape of the neck, and appears as pustules that leave deep, variola-like depressions 
behind. Irritation of the sebaceous glands by certain medicinal substances, either 
coming into the follicles from without when applied to the skin, or taken internally 




Fig. 117. — Acne pustulosa. 

From photograph by the author. 



230 



ILLUSTRATED SKIN DISEASES. 



and excreted through the sebaceous glands, causes an artificial acne. This may 
occur from the application of paraffin, tar, oil of cade, creosote, petroleum, etc. (acne 
medicamentosa s. picealis). The internal use of iodine and bromine may have the 
same result. The iodine acne appears as large conical infiltrations on vivid red bases, 

while bromine causes more extensive infil- 
trations with suppurative destruction of the 
follicles and surrounding tissue. These 
various drugs have been demonstrated in 
the secretion of the glands. 

Acne in its superficial and slightly 
marked forms is a trivial disorder, but in its 
severer ones it is a serious evil. This is 
more especially the case in the female, since 
it occurs during the years when marriage is 
most frequently contracted. It is always 
a very chronic and often a very obstinate 
disease. 

Etiology. — Mechanical irritation from 
inspissated and changed sebum, and infec- 
tion with pus-cocci, are the immediate 
causes of the development of the acne 
lesions. In the acne from the internal use 
of the bromides and iodides the noxious 
material is excreted with the products of 
the glands ; in those from the use of tar, 
pyrogallol, chrysarobin, etc., it reaches these 
organs from without. But the real reason 
of the inspissation and change in secretion 
is often obscure. The most important fac- 
tor of all is undoubtedly the advent of pu- 
berty. The sebaceous glands at that time 
participate in thegeneral glandular develop- 
ment, there being a close physiological re- 
lationship between the genital organs and 
the skin, as Hyde has pointed out (antlers 
of the stags, plumage of birds). Uterine 
diseases and disorders of sexuality are undoubtedly important factors. Gastroin- 
testinal disturbances, general cachexias, anemia, chlorosis, etc., are the causes of 
some cases. But acne not infrequently occurs in otherwise perfectly healthy in- 
dividuals. 

Pathology. — The anomaly of secretion causes a folliculitis of the sebaceous 




Fig. 1 1 8.— Acne bromata. 
Case of Professor Elsenberg, Warsaw, Poland. 



INFLAMMATIONS. 231 

glands, and to this there succeeds a varying amount of perifollicular inflammation, 
often ending in suppuration. The glands are frequently destroyed, but the hairs 
are lost only in the worst cases. The deeper-seated nodules and pustules lead to 
permanent scarring! 

Diagnosis. — The age of the patient, the seat of the eruption on the face and back, 
the acute course of the individual lesions and the chronic course of the entire malady, 
the presence of comedones, seborrhea, and dermic abscesses, with the absence of 
grouping, ulceration, and crusting, sufficiently distinguish the malady. Its diagno- 
sis from the early pustular syphiloderm is sometimes difficult ; but the latter has 
greater infiltration, is copper- colored, affects the whole body, and often the palms 
and soles, is grouped, and is almost always associated with other syphilitic symp- 
toms. The tertiary pustular lesion of syphilis is grouped and has characteristic crusts 
and spreading ulcerations. Variola sometimes resembles an acne ; but the umbilica- 
tion of the pustules, their acute course, and the presence of general symptoms should 
prevent mistakes. Rosacea occurs almost always after the thirtieth year, affects 
the middle two thirds and not the sides of the face or the back, and shows marked 
hyperemia and dilated vessels; and, though acne pustules are frequently present, 
there is no danger of confounding the two diseases. 

Prognosis. — This is good ; spontaneous recovery occurs in most cases before 
the twenty-fifth year, and few last beyond the thirtieth. Successful treatment 
depends much on our ability to discover and remove the cause. Permanent cica- 
trices and keloidal scars occur in some cases. 

Treatment. — The removal of the cause of the acne, if such can be found, is the 
first essential of successful treatment. Dyspepsia and constipation must be carefully 
attended to, saline cathartics and the laxative mineral waters being regularly em- 
ployed. Anemia and chlorosis must be treated with iron, bitter tonics, and the 
mineral acids; and here Startin's mixture (No. 19, p. 64) is especially serviceable. 
The uterine functions must be carefully inquired into and any anomalies corrected. 
The use of iodine, bromine, and their salts must be stopped, and external irritants, 
dust, tar preparations, etc., must be kept away from the skin. The diet should be 
carefully regulated, and usually much restricted, more especially as regards meats. 
Confectionery, pastry, pickles, etc., must be entirely forbidden. Obstinate cases 
should be restricted to a diet of fish, fruit, and light vegetables, and it is sometimes 
necessary to put our patients on a strict milk diet. The care of the general health 
is of the utmost importance ; fresh air, bathing, and exercise must be sufficiently 
provided for. An excellent general measure is the daily sponging of the body with 
salt water as cool as can be borne, followed by a vigorous rubbing with a rough 
towel. 

Internal treatment directed to the acne itself is not of much use. Ichthyol in 
pill form has seemed to do good in some cases (No. 120, p. 232). Cod-liver oil is 
effective in the frankly suppurative cases. 



232 ILLUSTRATED SKIN DISEASES. 

Local treatment is our main reliance, and of the many methods that have been 
advocated, the use of the curette, combined with massage and friction, is, in my 
experience, the best. The first step is to remove all comedones with the extractor 
(Fig. 1 6, p. 50), or by lateral pressure with the flat metallic handle of the scarifica- 
tor or other instrument. A watch-key is a very inappropriate instrument for the pur- 
pose, since it cannot be kept clean and unnecessarily injures the skin. Then all nod- 
ular masses and pus collections must be thoroughly opened with the spud (Fig. 23, 
p. 51) or a tenotomy knife, care being taken to go deep enough to open up the 
infiltrations. Multiple punctures are required in the more extensive infiltrations, 
and even when no pus is obtained the opening up of the inflamed tissues and the 
slight hemorrhage do good. The entire affected skin must be thoroughly worked 
over with the dermal curette (Figs. 18, 19, 20, p. 50), the tops of all papules and 
infiltrations being torn off and the superficial epidermis and sebum removed. This 
process of comedo extraction, puncture, and curetting must be repeated once in 
three to ten days, in accordance with the sensitiveness of the patient's skin. 

No. 120, Ichthyol Pills. No. J2I. Lassen's Peeling Paste. 

R Ammon. sulph-ichthyolat. . 3iii R /3-naphthol ... 1 part 

Extr. glycyrrhiz. . q. s. ft. pil. No. 90 Sulph. praecip. ... 5 parts 

Sig. 2 to 4 t. d. Petrolati 

Sapon. virid. . . aa. 2 " 

Meantime the patient must employ certain auxiliary measures. Once or twice 
daily, or every other day, steaming, massage, and friction of the face must be per- 
formed, to stimulate the muscular structures of the skin and prevent the accumu- 
lation of epidermis, sebum, and dirt in the glandular orifices. With the head bent 
over a basin of steaming hot water, the face must be bathed continuously with a 
clean sponge or cloth for from fifteen to twenty minutes. The face is then vigor- 
ously rubbed with the tincture of green soap (No. 5, p. 43), washed off, and anointed 
with a mild sulphur ointment (Nos. 24, 25, p. 64). 

These measures will suffice in the milder cases ; but many severer ones are met 
with, in which the papules, pustules, and dermic abscesses continue to appear, and 
more radical measures are required. A peeling paste must be employed, to cause 
a desquamation of the epidermis and remove the accumulated material from the 
skin. I have found the one suggested by Lassar (No. 121, p. 232) efficacious ; it 
should be spread over the face as thick as the back of a table-knife, and allowed to 
remain on for half an hour or until vigorous burning sets in. It is then wiped off 
with a soft cloth, and cold-cream (No. 69, p. 135) or simple ointment (No. 26, p. 70) 
applied, followed by a powder (No. 18, p. 61). This is repeated daily for from 
four to six days, until redness, swelling, and tension of the skin, followed by des- 
quamation, set in. Then a mild powder or ointment is employed for a number of 
days ; and the process is repeated as often as may be necessary. The resorcin-sali- 




COPYRIOHT BY E. B. TREAT 4 CO., N. Y. PHOTOGRAVURE AND COLOR CO., N. Y. 



ROSACEA 



PLATE XLII. 



J 



-sulphur pa.-- 
sublimate solul 

Other lo 
icht 

the sulphur ; 
curetted should be c< 
which hastens the ab- 









ft 

Relapses are very prone to c c 
ment of the cause underlyi 
the skin. For this latter objec r 
soap and plenty of hot wai 

Synonyms. — Acne rosacea, 
■/ rosee, t 
Definition. — A chr 

the nose, cheeks, and chin, char-, 

integument of ti 
Symptoms and Course 
I oration of the skin 
time to time after the ingest 
coughing, excitement, e 
and somewhat smooth skin 
dusky red and cold wher 
course. In its first and s 
to the !. 
manent and has spread c 

reddish < 

>me case 
Most cases i 
where wine 



INFLAMMATIONS. 233 

cylic-sulphur paste can be used in the same way (No. 42, p. 100), or the i-per-cent. 
sublimate solution may be employed. 

Other local applications that can be recommended are the 5- to 10-per-cent. 
ichthyol salves, pastes, and varnishes (No. 85, p. 165, Nos. 87, 88, 89, p. 169), and 
the sulphur lotion (No. 122, p. 233). Extensive hard infiltrations that cannot be 
curetted should be covered with the emplastrum or collemplastrum hydrargyri, 
which hastens the absorption of the inflammatory material. 

No. J22. Sulphur Lotion. 

fy Sulphur, prsecip. 

Aq. amygdal. . . . aa. 1 part 
Aq. calcis ... 5 parts 

Relapses are very prone to occur. We must endeavor to prevent them by treat- 
ment of the cause underlying the acne and by careful attention to the hygiene of 
the skin. For this latter object the chief means is the free use of a good non-irri- 
tant soap and plenty of hot water. 

ROSACEA. 

Synonyms. — Acne rosacea, brandy or wine nose, Kupferfinne, Kupfemase (Ger.), 
acne rose'e, couperose (Fr.). 

Definition. — A chronic inflammation of the skin of the face, more especially of 
the nose, cheeks, and chin, characterized by the presence of diffuse redness, dilated 
blood-vessels, and inflammatory papules and pustules, and ending in hypertrophy of 
the integument of the part. 

Symptoms and Course. — This common affection begins as a diffuse hyperemic 
discoloration of the skin of the nose, chin, cheeks, and forehead, which occurs from 
time to time after the ingestion of food, and especially of alcohol, and after laughing, 
coughing, excitement, exposure to cold, etc. Its color is bright red, with a tender 
and somewhat smooth skin, when the hyperemia is mainly arterial ; and bluish or 
dusky red and cold when it is venous. Three stages are to be distinguished in its 
course. In its first and slightest form the diffuse pink or dusky redness is confined 
to the nose and disappears on pressure. In the second stage the redness is per- 
manent and has spread on to the forehead, cheeks, and chin. The smaller arterioles 
and veins are permanently dilated and appear on the surface as minute tortuous 
reddish or bluish lines. Inflammatory nodules and pustules now appear, and form 
in some cases so prominent a part of the disease that it is often called acne rosacea. 
Most cases do not go beyond this stage ; but sometimes, especially in the countries 
where wine or beer is the daily beverage, the third stage of rhinophyma or 
Pfundnase completes the cycle of changes in the integument of the face. Over- 



234 



ILLUSTRATED SKIN DISEASES. 




growth of the connective tissue of the skin is added to the hyperemia, vascular dila- 
tation, and acneform manifestations. Small outgrowths appear on the nose, and 
gradually enlarge and coalesce until they form violaceous or livid, pedunculated or 
sessile tumors and masses of varying size. The sebaceous glands become 

enormously enlarged, and the dilated ducts 
are plugged with dark, hard masses of inspis- 
sated sebum. In the worst cases the deform- 
ity is a very serious one, and the discolored 
hypertrophic mass hangs down in front of the 
mouth. On the cheeks and forehead the 
connective-tissue hypertrophy is usually not 
marked, and the process remains in the second 
stage. This third stage of rosacea is, strange 
to say, found in the male subject only. 

Seborrhea of the dry or the oily variety 
is a regular accompaniment of rosacea, and 
forms a marked feature of the last or hyper- 
trophic stage. The inflammatory follicular 
and perifollicular lesions are essentially the 
same as those of acne, and the papules and 
pustules are sometimes so numerous that the 
diagnosis between the two affections is diffi- 
cult. Suppuration of the glands and follicular abscesses also occur. 

Etiology. — Rosacea has many causes, and in a general way is due to anything 
that causes congestion of the head. The commonest of these causes is the abuse of 
alcohol ; but it is by no means the only one, and the malady occurs on many people 
who do not drink at all. Chronic dyspepsia, especially when associated with gastric 
dilatation, often determines its appearance ; and since drinkers usually suffer from 
this affection, there are two causes for the rosacea in these cases. Sexual dis- 
turbances, and more especial!}- uterine derangements (endometritis, dysmenorrhea, 
etc.), are efficient causes and account for many of the cases seen in women. Sud- 
den changes of temperature, such as firemen, cooks, etc., are subject to, are also 
causative, and more or less rosacea is generally present in those whose occupation 
exposes them to the weather — coachmen, sailors, etc. Parts that have once been 
frozen are especially liable to become rosaceous. 

Pathology. — The process is in the beginning a hyperemic stasis, affecting both 
the deep and the superficial vessels of the skin. This is followed by a hypertrophy 
and overgrowth of these structures, which is so characteristic a feature of the dis- 
ease that the malady might be classed as a vascular new growth. Inflammation of 
the glands and the periglandular tissue ensues, and a connective-tissue new growth 
gives us the final stage of the disease. 



Fig. ng. — Rhinophyma. 

Case of Dr. F. B. Carpenter. 



INFLAMMATIONS. 235 

Diagnosis. — This is usually readily made, in spite of the varied appearance of the 
malady. The mature age of the patient, the localization of the eruption upon the 
face, and the vascular and connective-tissue overgrowth are characteristic points. 
Rhinophyma is not likely to be confounded with rhinoscleroma, which is a very 
hard, smooth, and shining tumor, usually growing from the interior of the nose and 
affecting the skin only secondarily. Lupus vulgaris shows the characteristic non-ele- 
vated, soft, brownish nodules, and has a distinct limitation, ulceration, and a scar-tissue 
formation in which the tubercles are found. Lupus erythematosus is of slow growth, 
has infiltrations covered with adherent fatty scales with plugs projecting from their 
under surfaces, and central scarring. The tubercular syphiloderm has dark-brown 
grouped tubercles and ulceration, and never shows vascular overgrowth or glandular 
inflammation. Acne papules and pustules commonly occur with rosacea; but acne 
is not limited to the face, being found also on the back and chest ; it is accompanied 
by comedones and inflammatory lesions, and there is no vascular hypertrophy. 

Prognosis. — This is good in mild cases, more especially when the cause can be 
removed. Much depends upon the energy with which an appropriate treatment is 
carried out. The diffuse redness is harder to remove than the newly formed vessels 
and connective tissue. 

Treatment. — A necessary preliminary to all measures directed against the rosa- 
cea itself is the treatment of any internal abnormality that may be present — more 
especially dyspepsia, and allied diseases of the gastro-intestinal tract, and uterine 
derangements. The use of alcohol must be entirely forbidden, and tea and coffee 
must be taken but sparingly. Very little can be done for the cases in which the 
rosacea is dependent upon the patient's occupation and in which the cause cannot 
be removed. In those necessarily exposed to the effects of wind and weather, or 
heat, our best efforts will be merely palliative. Ichthyol in i- to 3-grain pills thrice 
daily has been recommended (No. 120, p. 232). Ergot in half-dram doses twice or 
thrice daily for long periods has done good in my hands, probably on account of its 
vasoconstrictor properties. 

The local treatment for mild cases is similar to that recommended for acne. We 
must distinguish between the arterial and the venous form of rosacea in our choice 
of topical remedies. In arterial rosacea, with a hot, dry skin, sulphur in 10-per-cent. 
paste or salve, or ichthyol in 5- to 10-per-cent. solution, ointment, paste, collemplas- 
trum, or varnish (No. 72, p. 137, Nos. 87, 88, 89, p. 169, etc.), may be ap- 
plied nightly, a bland ointment or cold-cream (Nos. 68, 69, p. 135), followed 
by a powder (No. 18, p. 61), being used during the day. If the skin becomes too 
much inflamed the zinc-oil (No. 65, p. 135) should be employed until the irritation 
subsides. 

Destruction of the dilated blood-vessels is necessary in all advanced cases, and 
may be effected in a variety of ways. If there are very many minute vessels visible, 
scarification may be employed, a limited area being " cross-hatched " in the artist's 



236 ILLUSTRATED SKIN DISEASES. 

manner daily or every few days. An ordinary bistoury or the scarificator (Fig. 15, 
p. 50) may be employed. Larger vessels should be split open lengthwise with a 
tenotomy knife, a very efficacious method of obliterating them. A small galvano- 
caustic point may be employed for the same purpose, a number of minute punctures 
being made along the course of the vessel, thus destroying it. Electrolysis has 
proved very serviceable in my hands, multiple punctures being made along the 
course of the vessel with the needle in the manner described under the treatment of 
hirsuties (p. 49). A very small amount of current, 2 to 5 milliamperes, suffices to 
occlude the vessel. 

FOLLICULITIS, 

Synonyms. — Sycosis non parasitica, sycosis coccygenes, perifolliculitis, mentagra, 
Bartfinne (Ger.), sycosis non parasitaire (Fr.). 

Definition. — A chronic suppurative inflammation of the hair-follicles and neigh- 
boring tissue, chiefly affecting the beard, and characterized by the appearance of 
papules, tubercles, and pustules pierced by hairs. 

Symptoms and Course. — Folliculitis begins with the appearance of small, red, 
hard, conical papules surrounding hairs, and scattered through the affected area or 
collected into groups. The papules are usually discrete, and they may increase in size 
so as to form tubercles and deeper nodules ; but as a rule the fluid exudation becomes 
sufficient to form a pustule. In the papules the centrally implanted hairs are firmly 
seated, and are removed only with pain ; the entire sheath is swollen and white or yel- 
lowish from infiltration with pus-cells. In the fluid of the pustules the hair and its 
sheath lie loose ; the pilous structure can be readily removed, and sometimes falls 
out of itself. The pus may be evacuated or it may dry up into a crust ; in any case 
the hair-follicle is destroyed and cicatricial tissue results. The continuous appear- 
ance of new papules in crops among the old ones may lead to the formation of more 
extensive infiltrations, in which the single papules can no longer be seen, and whose 
surface is covered with pustules and crusts pierced with hairs. Considerable losses 
of tissue may thus occur. Burning and itching, sometimes very considerable, ac- 
company the process. 

The malady is a very chronic one ; advancing irregularly with the appearance of 
new papules, it may last for years confined to a limited area, or it may slowly spread 
over extensive surfaces of integument. Fully developed cases show a reddened, 
swollen, infiltrated skin covered with papules, pustules, crusts, and scales, and the 
entire hairy portion of the face is usually affected symmetrically. Sooner or later 
most of the hair-follicles are destroyed and their place is taken by cicatricial tissue. 
Old cases show a more or less completely cicatricial surface, in which there may remain 
a few scattered and badly nourished hairs. 

Folliculitis is commonest on the bearded face and the mustache, but it may ap- 




COPYRIGHT BY B. 6. TREAT A CO., N. Y. PHOTOGRAVURE 4 COLCR CO., N. Y. 



PERIFOLLICULITIS BARBAE. 



PLATE XXXV. 




h 

the mali 

variety of the barber', 
en. 
Etiology.- - 

; 
le hair-. with 9[ 

pus-cocci, most con ■ 

neans of brushes, tow- 

of the skin by h 

aps, p<:. 
Mctics, i he ^H 

or that predisposes tl 

■ o their reception. Ec- 

i is a not infrequent 

prelude to the appearance 

the disc ; 

onic rhinitis that so com- 
monly coexi: 
affection upon 

lip is indi ! ^^^B 

for the folliculitis. 

Pathology. — T I 
case is an acute suppura- Hi 

• inflammation 
folh ■illcular 

.structures, leading to the 
destruction of the hai 

which varies in am 
The term " non-parasitic syc 

Diagnosis, — Tl 

pierced by an a 

the very chronic cour 

beard, or para 

I 







INFLAMMATIONS. 



237 



pear in any locality that is provided with strong hairs. It is found in the eyebrows 
and lashes, and occasionally occurs in the nostrils, and on the axillae, pubis, and other 
portions of the body. It is rarest upon the head. It occurs almost invariably in 
the male sex, being one 
variety of the barber's itch 
of laymen. 

Etiology. — Folliculitis 
is caused by the infection 
of the hair-follicles with 
pus-cocci, most commonly 
by means of brushes, tow- 
els, pillows, etc. Irritation 
of the skin by heat or cold, 
noxious soaps, powders, 
or cosmetics, etc., is the 
factor that predisposes the 
soil to their reception. Ec- 
zema is a not infrequent 
prelude to the appearance 
of the disease, and the 
chronic rhinitis that so com- 
monly coexists with this 
affection upon the upper 
lip is indirectly responsible 
for the folliculitis. 

Pathology. — The dis- 
ease is an acute suppura- 
tive inflammation of the 
follicular and perifollicular 
structures, leading to the 

destruction of the hair-follicles and papillae. The gaps are filled with cicatricial tis- 
sue, which varies in amount with the depth and extent of the destructive process. 
The term " non-parasitic sycosis" is a misnomer, since the disease is due to cocci- 
genic infection. 

Diagnosis. — This is usually not difficult. The minute papules and pustules, each 
pierced by an apparently unaffected hair, usually beginning on the upper lip, and 
the very chronic course, are characteristic. Trichophytosis barbae, ringworm of the 
beard, or parasitic sycosis, is more acute, progresses continuously, often shows ring- 
worm on other parts of the body, has round, sharply limited affected areas or deep 
nodular and suppurating masses ; the hairs are early affected, becoming loose and 
brittle, and break off with frayed ends ; the malady is contagious ; and the parasite 




Fig. 120.— Folliculitis barbae. 

From photograph by the author. 



238 



ILLUSTRATED SKIN DISEASES. 



can be readily demonstrated under the microscope. Eczema may occur with follicu- 
litis ; when it appears alone it shows moist, red, not sharply limited surfaces, cov- 
ered perhaps with scales and scabs ; and the isolated lesions are not pierced by hairs. 

Acne occurs on the non- 
bearded parts, chiefly in young 
persons ; and the lesions are 
not situated around hairs. The 
tubercular syphiloderm has 
copper-colored infiltrations of 
slow development, and causes 
no pain ; ulceration and other 
syphilitic symptoms are pres- 
ent, and it reacts to specific 
treatment. 

Prognosis. — This is not en- 
tirely favorable ; the malady is 
curable, but relapses are fre- 
quent. It may last for a few 
weeks or for many years. The 
greater the amount of suppu- 
ration, the more destruction of 
tissue will there be. 

Treatment. — The treat- 
ment is a local one, and con- 
sists, in the first place, in treat- 
ing the eczema or the rhinitis 
that may be at the base of the disease. The hair over the affected area should be 
cut short, shaving being painful and tending to spread the infection. Crusts and 
scabs must be removed with compresses of olive-oil or poultices, aided by the use 
of the tincture of green soap when necessary (No. 5, p. 43). 

Irritation of the skin should be allayed by a simple or cooling ointment (No. 26, 
p. 70, No. 29, p. 74, Nos. 68, 69, p. 135). Later on diachylon ointment (No. 71, 
p. 136) or Lassar's paste (No. 2, p. 43) is useful. In bad cases the resorcin-salicylic- 
sulphur paste (No. 42, p. 100) or the tannin-sulphur paste (No. 50, p. 108) should 
be applied until peeling occurs. The salicylic-sulphur paste (No. 79, p. 153) has 
done me good service in some cases. The combination of 1 or 2 per cent, of the 
oleate of mercury with simple ointment is also efficacious. 

In all the severer cases removal of the hairs becomes necessary. This can be 
readily effected without pain, as soon as suppuration has loosened the hair, by 
means of the epilating forceps (Fig. 22, p. 51); one hair is seized at a time, and 
removed by a sudden sharp traction. The hair-root and -sheath are infiltrated 




Fig. 121.— Folliculitis. 

From a cast by the author. 



INFLAMMATIONS. 239 

with a multitude of pus-cocci ; epilation removes them and opens the follicle for the 
exit of pus and for the entrance of medicaments. It must be systematically carried 
out, together with the other treatment; in most cases it is sufficient to remove all 
the hairs seated in pustules once or twice a week. 



4. INFLAMMATIONS OF THE NAILS. 

The nails are non-vascular structures, and the inflammatory processes that affect 
them take place in the nail-bed, the falx, arid the matrix ; the nail itself being only 
secondarily involved. The process may be primary and idiopathic, or it may occur 
secondarily to inflammatory or parasitic diseases of the general integument. 

ONYCHIA. 

Inflammation of the nail-bed occurs rarely as an idiopathic affection, as from 
traumatisms ; more frequently it forms a part of other inflammatory skin affections, 
such as psoriasis, eczema, the syphilodermata, etc. The nails become thickened, 
lusterless, and furrowed, and the nail-bed becomes inflamed and tender. The ap- 
pearance of the affected nail itself is rarely characteristic, and we must usually rely upon 
the symptoms of disease that are generally present at other points for the diagnosis. 
The treatment should consist in the removal of the cause, where that is ascertainable, 
the relief of tension by incisions, or possibly by the removal of the nail, followed by 
an iodoform or boric-acid dressing. The further treatment is that of the underlying 
disease. 

Onychia maligna is a chronic or acute inflammation of the nail- bed occurring in 
debilitated and cachectic individuals, more especially in children affected with chronic 
inflammations of the glands or mucous membranes (so-called scrofulous or stru- 
mous individuals). It is possibly due to a local tubercular infection. The nail is 
thickened, opaque, discolored, and raised from its bed ; the matrix and falx are in- 
flamed, and suppuration may occur ; and after the nail is loosened or cast off the 
bed undergoes an ulcerative or granular inflammation. The affection is very pain- 
ful, and several nails, either at one time or consecutively, are usually involved. 
The nails are usually lost, and are replaced either by a deformed and irregular organ, 
or by cicatricial tissue ; occasionally the whole phalanx is destroyed. The local 
treatment consists in the removal of the nail and the treatment of the affected area 
by general surgical measures, together with tonic treatment. 

Paronychia, whitlow, inflammation of the tissues around the nail-bed, occurs 
occasionally spontaneously from excessive growth of the nail, but is more commonly 
caused by pressure, as of improper footwear. One of the upper angles of the great 
toe-nail is usually affected. Hypertrophy of the nail is generally present, and will 



240 ILLUSTRATED SKIN DISEASES. 

be considered under its appropriate heading. The treatment consists in the relief 
of pressure, the repression of exuberant granulations with the nitrate-of-silver stick, 
the use of sedative or astringent ointments, iodoform, etc. (No. 29, p. 74, No. 54, 
p. 113, Nos. 68, 69, p. 135). If ingrowing toe-nail is present, it must be appro- 
priately treated. 

ONYCHOMYCOSIS. 

All the parasitic affections of the nails look so much alike that they may be con- 
sidered under one heading. The nails lose their gloss and become spotted and dirty 
yellow; they are ridged, furrowed, and brittle. The prognosis as to the preserva- 
tion of the nail in bad cases is doubtful. In favus the anterior ends become thick- 
ened, and chip or split off, and dust-like masses of parasite are visible under them ; 
but the diagnosis here also must be made from the presence of the disease elsewhere, 
since in the nail itself the fungus is difficult to demonstrate. The frequent use of 
hot water, green soap, and a stiff brush is useful in all cases. The treatment for 
ringworm of the nails consists in thorough scraping, followed by the application of 
sulphurous acid or the hyposulphite of soda (1 to 4 of water) on lint covered with 
oiled silk. In favus the nails may be soaked in a warm 40-per-cent. solution of caus- 
tic potash, and then scraped, and a parasiticide ointment applied (No. 74, p. 138, 
No. 37, p. 82, etc.). The i-per-cent. sublimate collodion is also useful. 



CLASS IV. 
HYPERTROPHIES. 



In this class of dermic changes the cells of the whole or of certain elements of 
the skin are increased in number. The epidermis alone may be affected, as in cal- 
lositas ; the papillae may be also involved, as in warts ; the pigment may be increased, 
as in chloasma; the hair may be multiplied, as in hypertrichosis; or the connective 
tissue may be chiefly involved, as in elephantiasis. 

U HYPERTROPHIES OF THE EPIDERMIS. 

These may be congenital or acquired, general or local, and include ichthyosis 
and keratosis, callus, callositas, clavus, verruca, cornu cutaneum, and the acuminate 
condyloma. 

ICHTHYOSIS. 

Synonyms. — Xeroderma, lichen pilaris, keratosis pilaris, fish-skin disease, Fisch- 
sclmppenkranklieit (Ger.), ichtJiyose (Fr.). 

Definition. — A congenital deformity of the skin, characterized by dryness and 
scaliness of the epidermis, and sometimes by horny, acuminate papules, plates, or 
larger warty masses. 

Symptoms and Course. — Ichthyosis is a deformity and not a disease. In its 
commonest and mildest form (xeroderma) the skin is rough, dry, slightly 
thickened, and its natural furrows are exaggerated; it is pearly white in 
color, and its surface is covered with a slight furfuraceous desquamation. The 
change may be so slight as to be discovered only accidentally. In some cases the 
epithelial accumulation occurs mostly around the hair-follicles, giving rise to small, 
acuminate, horny masses either surrounding a hair or containing a small curled-up 
hair within them (lichen s. keratosis pilaris). A somewhat severer form is known as 
ichthyosis simplex, in which the epithelial formation is so rapid that the scales ac- 
cumulate as polygonal, dry, white or pearly scales or plates, giving the surface a tes- 

241 



242 ILLUSTRATED SKIN DISEASES. 

sellated appearance (ichthyosis serpentina). Here the color is darker and may even 
be brownish or greenish black. The scales are attached with moderate firmness, but 
they can be removed without causing bleeding. The nails are friable and thickened, 
and the scalp is scaly, as in seborrhea. 

Ichthyosis hystrix is rare, and is rather a distinct form than an advanced stage 
of the preceding. Here the corneous scales accumulate to form rough, irregular, 
heaped-up masses of tissue, spines, or larger warty eminences, projecting half an inch 
or more above the surface, and yellow or brownish black in color. The scales and 
masses are occasionally shed, as if by a process of moulting ; but they soon reaccumu- 
late. Extreme instances of the deformity pose as curiosities under the name of por- 
cupine or hedgehog men; the Lambert family was a notable example during the 
last century, three generations having been affected. Ichthyosis congenita com- 
mences in intra-uterine life. The children are born small and puny, the entire body 
being covered with horny plates and scales, traversed by deep fissures, and looking 
like a covering of armor. The growing fetus has split and fissured the resistant 
integument ; the lips, eyelids, and external ears are wanting, and the fingers and 
toes are cramped and bent by the unyielding skin. These cases live only a few 
days, dying from the loss of heat, impossibility of suckling, etc. 

Ichthyosis may extend over the entire skin, or it may be localized ; but the 
extensor surfaces of the limbs are always most affected, and the deformity may be 
present in these locations only. The backs of the hands and feet are often involved, 
as are also the thighs, shoulders, and trunk. The face, palms, and soles are often 
free. In bad cases, however, ectropion and deformity of the lips ensue from the 
unyielding texture of the skin. The simple forms are usually more or less general, 
but ichthyosis hystrix is rarely symmetrical, and the lesions often follow the track 
of the cutaneous nerves. 

A marked feature of the disease is the diminution in the secretion of both the 
sebum and the sweat. Yet the general health of these patients is good even in 
advanced degrees of the affection. As a rule no sign of it is visible at birth, but it 
appears during the first or second year, showing first at its points of election, the 
elbows and knees. It gradually advances until puberty is reached, at which time 
there is often a marked increase in its severity ; and thereafter it is but little subject 
to change. It improves in summer, when the sweat-glands are more active, and 
gets worse in the winter. 

Etiology. — Ichthyosis is a congenital deformity, the real cause of which is entirely 
unknown to us. It is often hereditary, either in the direct line, or in alternate gen- 
erations, or by a collateral branch ; sometimes one sex only in a family is affected. 
It is very common in Paraguay, and in the Moluccas 5 per cent, of the male popu- 
lation is said to show its manifestations. 

Pathology. — The process is a true hyperkeratosis. Robinson found the corne- 
ous layer hypertrophied, consisting of many superimposed layers of cells, and the 




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HYPERTROPHIES. 243 

sebaceous glands imperfectly developed ; the other elements of the skin were unaf- 
fected. The dark color of the scales is due to increased pigment formation and 
extraneous particles. In ichthyosis hystrix the papillae are surmounted by dense 
epidermoidal cones. 

Diagnosis. — This hardly ever presents any difficulties. The hereditary history 
and the development soon afterbirth; the dry, rough, furrowed skin of xeroderma; 
the horny papillae of keratosis pilaris; the plates and scales of simple ichthyosis; 
and the warty outgrowths and more extensive keratoses of the hystricoid form, are 
characteristic. The absence of inflammatory symptoms and of the peculiar primary 
lesions will serve to distinguish the disease from psoriasis, lichen planus, etc. 

Prognosis. — This is bad as to cure, but the general health remains unaffected. 
Cases other than the very mildest can only be relieved. 

No. 123. Resorcin Ointment No. 2. No. 124. Salicylic-acid Ointment. 

R- Resorcin. albiss. . . 2 parts Ac. salicyl. ... 2 parts 

Ungt. simplicis. . . ad. ioo " Petrolati . . . ad. ioo " 

No. J25. Naphthol Ointment. 

fy /3-naphthol ... 5 parts 

Solve in spir. vini rectif. q. s. 
Petrolati . . . ad. 100 " 

Treatment. — This can be merely palliative in almost all cases. Good results 
have been claimed from the use of pilocarpine given subcutaneously in f--grain 
doses, and arsenic may be tried; but internal treatment is of little avail. Continu- 
ous local treatment may do much to render the patient's condition a more tolerable 
one. A daily hot bath, alkaline or bran (p. 41), preceded by frictions with green 
soap, should be prescribed. After that an oleaginous or other emollient preparation 
should be used, and for that purpose linseed, olive, benne, or any other oil may be 
employed. Cod-liver oil is very good, though slightly objectionable on account of its 
odor; in very mild cases a glycerin lotion, 1 to 10, is quite sufficient. After the 
scales are removed severer cases require a 2-per-cent. resorcin or salicylic-acid oint- 
ment (Nos. 123, 124, p. 243). Kaposi recommends naphthol, either alone (No. 125, 
p. 243) or with green soap (No. 37, p. 82). In localized forms of ichthyosis the re- 
sorcin or salicylic-acid collemplastra may be employed. In ichthyosis hystrix the 
warty growths may be curetted, or they may be removed by means of a saturated 
solution of salicylic acid in alcohol ; then one of the above ointments should be used. 
The treatment selected must be persisted in indefinitely. 

KERATOSIS PILARIS. 

Synonyms. — Pityriasis pilaris, lichen pilaris. 

Definition. — An accumulation of corneous cells at the orifices of the hair- 



244 ILLUSTRATED SKIN DISEASES. 

follicles, forming numerous minute grayish- or pinkish-white acuminate hard 
papules. 

Symptoms and Course. — Keratosis pilaris appears as pinhead-sized, hard, conical 
papules situated at the orifices of the hair-follicles. Their color is similar to that of 
the skin, or pinkish or grayish white. The hair of the follicle pierces the papule, or 
is broken off level with its apex, appearing as a minute dark point, or is coiled up 
among the epithelium-cells. The extensor surfaces of the limbs, more especially of 
the thighs and arms, are the usual site of the disease ; but the trunk is occasionally 
involved. In bad cases the skin feels like a nutmeg-grater and is fairly studded 
with the conical grayish horny prominences. Sometimes the malady occurs in con- 
junction with xeroderma or ichthyosis. It occasions no subjective symptoms. 

Etiology. — The affection occurs most frequently in persons more or less subject 
to ichthyotic deformity of the integument, and heredity is undoubtedly influential in 
determining its appearance. Personal uncleanliness naturally increases the tendency 
to the accumulation of epithelial detritus upon the skin, and intensifies the condition. 

Pathology. — The papules are accumulations of cells of the horny layer of the 
epidermis, mixed with a little inspissated sebum. The mass is seated in a minute 
depression around the orifice of the hair-follicle, from which it can be shelled out. 

Diagnosis. — Its seat upon the extensor surfaces of the limbs, and the character- 
istic minute acuminate horny papules at the mouths of the hair-follicles render ker- 
atosis follicularis readily distinguishable. Ichthyosis is not limited to the hair-follicles, 
and the entire absence of inflammatory symptoms will serve to distinguish the affec- 
tion from a papular eczema. 

Treatment. — This is essentially the same as that of the milder forms of ichthyo- 
sis. Alkaline, vapor, and hot baths, the free use of soft soap and the flesh-brush, 
together with inunctions of the various bland oils, will keep the process in abeyance 
and will sometimes cure it. 

CALLOSITAS. 

Synonyms. — Tyloma, keratoma, callus, Schwiele (Ger.). 

Definition. — A localized thickening of the corneous layer of the skin, gradually 
sloping down to the healthy integument. 

Symptoms and Course. — Callositas is rare as a congenital condition, being usually 
acquired on parts exposed to intermittent pressure or to friction, more especially 
over the various bony prominences. It appears as a finger-nail-sized and larger 
biconcave lens-shaped mass, seated in a depression of the epidermis. It is semi- 
transparent, and of a dirty grayish- or brownish-white color; the normal folds of 
the skin are obliterated and the tactile sensibility is lessened. Rhagades, inflamma- 
tory processes, and suppuration not infrequently occur, and complete exfoliation 
may take place. 

The size, number, and location of the callosities vary with their cause, are more 



HYPERTROPHIES. 



245 



or less characteristic of the different occupations that occasion them, and are some- 
times essential to work. Thus they are found upon the hands of mechanics, more 
especially of metal-workers and shoemakers ; on the hands of musicians at the 
places that come in contact with the strings ; 
on the soles of the feet of those whose 
occupations compel them to stand or walk 
much, or who wear ill-fitting shoes ; and on 
the body from the pressure of trusses and 
other apparatus. Though essentially pro- 
tective, they may occasion discomfort from 
the pressure of the mass upon the deeper 
layers of the derma, the Assuring or the 
inflammatory action in the surrounding tis- 
sue, and the interference with the tactile 
sensibility ; they may even interfere with 
the patient's vocation, or render walking 
impossible. 

Etiology. — Long-continued and inter- 
mittent pressure is the usual cause of cal- 
losities; more rarely they are due to the 
action of some chemical agent, lye, etc. In 
some cases the cause is not to be ascer- 
tained. 

Pathology, — A callosity is a simple in- 
crease in the corneous layer of the skin, 
the cells of which are more coherent than 
usual. There is a depression of the deeper 
tissues at the site of the tumor, but other- 
wise they are entirely normal. 

Diagnosis and Prognosis. — The diagno- 
sis never presents any difficulties. The 
prognosis as to recurrence after removal is 
good; but it must be remembered that in 
many cases the formation of the callosity 
is conservative, protecting the deeper struc- 
tures from mechanical injury, and is neces- 
sary in the patient's occupation. 

No. J26. Salicylic-soap Ointment. 

.3 parts 

. aa. 5 " 



1 





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Fig. 122. — Callositas. 

From photograph by the author. 



No. 127. Salicylic- Cannabis Collodion. 



R: Ac. salicyl. 
Sapon. virid. 
Petrolati . 



fy Ac. salicyl. 

Extr. cannabis indie. 
Collod. flex. . 



10 parts 
1 part 
100 part 



246 ILLUSTRATED SKIN DISEASES. 

Treatment, — The protective callosities must not be interfered with. In other 
cases the cause must be removed, proper shoes must be worn, and the local injuries 
that cause the development of the epithelial overgrowth must be avoided as far as 
possible. Soaking with hot water, maceration with oil, green-soap frictions, or 
poulticings are useful to soften the thickened epidermis and facilitate its removal. 
The mass can then be shaved off with the scalpel, the 20-per-cent. salicylic plaster- 
mull, the 10-per-cent. salicylic collodion, the salicylic-cannabis collodion (Xo. 
127, p. 245), the salicylic-soap ointment (No. 126, p. 245) being afterward employed. 
Pure salicylic acid can be sprinkled over the surface, and the callosity then covered 
with gutta-percha paper and plaster. These measures will after a time transform 
the thickened corneous layer into a swollen soft white mass, which can be removed 
from the underlying tissue without trouble. Inflamed or suppurating callosities 
must be poulticed, to promote the separation of the cornified tissue. 



. CLAVUS. 

Synonyms. — Corn, Hilhnerauge, Leichdom (Ger.), cor (Fr.). 

Definition. — A circumscribed callosity, usually situated upon the toes, and pro- 
vided on its under surface with a conical spur of corneous tissue fitting into a de- 
pression in the corium. 

Symptoms and Course. — A corn is a circumscribed, grayish- white, hard or soft 
hypertrophy of the epidermis, with one or more projections from its lower surface. 
It is usually situated over a bony prominence, more especially upon the toes and the 
soles of the feet ; more rarely it occurs upon the hands. It varies in size from a 
small pea to a chestnut. On the exposed surfaces its texture is dense ; but under 
the influence of heat and moisture, as between the toes, it becomes macerated and 
Soft. Corns are painful from the pressure exerted by the projecting spur upon the 
sensitive papillae and corium, and are also sensitive to weather- changes. 

Etiology. — Corns are almost always due to pressure and friction from the use 
of improper footwear. 

Pathology. — The corneous layer at the affected place is increased, the epithelial 
cells being more coherent than normal, and arranged in superimposed and sometimes 
concentric layers. The corium is thinned and atrophic from the pressure of the 
downward-projecting mass. Bursae frequently form between the lower surface of 
the corn and the bone beneath. 

Diagnosis and Prognosis. — Removal of the corn is easy; but pyemia has occa- 
sionally followed operative interference with these growths, most probably from the 
opening of the bursa that are formed underneath the corn in the absence of proper 
antiseptic precautions. 

Treatment. — This is essentially the same as for callositas. Prophylaxis consists 



HYPERTROPHIES. 



247 



in the wearing of proper footwear and the removal of pressure from the part by the 
use of concentric rings of plaster. The hypertrophic tissue can be removed with 
the knife or the curette after softening it with hot water or oil; but operative in- 
terference is rarely necessary. Duhring recom- 
mends the use of a 4- to 8-per-cent. caustic- 
potash solution, after carefully protecting the sur- 
rounding parts with rubber plaster. The salicylic- 
cannabis collodion (No. 127, p. 245) is the most 
useful application in ordinary cases; it should be 
painted over the corn several times daily for a 
week, at the end of which time the hypertrophied 
mass can be easily picked off. Soft corns can be 
removed by the use of the ointment of the nitrate 
of mercury or the nitrate-of-silver stick. Inflamed 
and suppurating corns must be poulticed until the 
hypertrophied mass comes away. 




CORNU CUTANEUM. 

Synonyms. — Cutaneous horn, Hauthorn (Ger.), 
come de la peau (Fr.). 

Definition. — A circumscribed hypertrophy of 
the epidermis, forming a various-sized and -shaped 
excrescence. 

Symptoms and Course. — Cutaneous horns are 
epithelial proliferations that project outward from 
the skin, forming cylindrical or pyramidal horny 
eminences. Their color is yellowish brown or 
greenish or blackish ; their texture generally hard, 
and laminated or fibrillated ; and their shape is 
straight or curved. They are of very rare occur- 
rence, and usually one only is present ; but sometimes there are several, and 
Hesch has described one case in which there were sixteen of these growths. They 
are usually small, the largest I have seen being 1 inch in size ; but they have been 
found of a size of 10 inches and more. They have been most often seen upon the 
face, scalp, and hands, and occasionally upon the genitals ; and I have seen one upon the 
sole of the foot. As a rule they fall off spontaneously after attaining a certain size ; 
and in a considerable proportion of cases they finally undergo malignant degenera- 
tion and develop into carcinomata. 

Etiology. — We are ignorant of the cause of these outgrowths, though some of 



Fig. 123. — Cornu cutaneum. 

From photograph by the author. 



250 ILLUSTRATED SKIN DISEASES. 

Sprinkling the surface with an astringent powder (No. 18, p. 61) or with iodoform 
and tannin (No. 128, p. 249) does very well; the salicylic dusting powder is more 
efficacious (No. 14, p. 58). Contiguous surfaces must be kept apart with cotton, 
bandages, etc. Chromic or carbolic acid may be employed in obstinate cases. 
Occasionally it is preferable to snip the growths off with the scissors, the liquor 
ferri sesquichloridi or carbolic acid being used afterward. The galvanocautery or 
electrolysis (p. 49) may also be used. 

VERRUCA. 

Synonyms. — Wart, Warze (Ger.), verrue (Fr.). 

Definition. — Various-sized, hard or soft, papillary or fiat elevations of the skin, 
due to a localized hypertrophy of the papillae and epidermis. 

Symptoms and Course. — The so-called congenital warts are hairy and pigmentary 
growths belonging to the class of the naevi ; we shall consider here only the common 
and the senile wart. 

Verrucas vulgares are small pinhead- to bean-sized, circumscribed growths pro- 
jecting above the surface of the skin, and firmly seated on broad and slightly indurated 
bases. They may be single or multiple ; they are usually isolated, but are occa- 
sionally found grouped into larger confluent masses. Their shape is conical or flat; 
and their dry and horny surface is often cleft and furrowed, giving to their tops a 
brush-like appearance. Their color is at first that of the skin, but later it becomes 
brownish or even blackish, from the accumulation of dirt in the interstices of the 
horny layer. Their seat is usually on the hands, more especially upon the fingers ; 
but they occur also upon the toes, trunk, face, and scalp. They grow quickly 
or slowly ; they may persist for an indefinite time, but they sometimes drop off 
spontaneously. They are seen in young individuals, and most commonly in 
males. 

Verrucse seniles s. planae are soft, smooth, and usually flat excrescences that 
appear on the face and the back of the aged. They vary in size from that of 
a pea to that of a finger-nail, and they are usually of a dark-brown or blackish 
color. 

Etiology. — The cause of ordinary warts is unknown ; the microorganisms that 
have been described have not been proved to be pathogenetic. There seems to be 
some ground for the popular belief in their contagiousness and auto-inoculability. 
The senile warts are an expression of the general tendency of the epithelial tissues 
to hypertrophy late in life. 

Pathology. — There is a localized hypertrophy of the papillae, enlargement of the 
capillary loops within them, and an enormous increase in the superincumbent corne- 
ous layers. 

Diagnosis, — This is of importance only with the senile warts, as regards their 




VERRUCA. 




TYPOGRAVURE. 



COPYRIGHT BY E. B. TREAT 4 CO. , N. Y. 



ALOPECIA AREATA. 



PLATE L. 



HYPERTROPHIES. 251 

differentiation from epitheliomata. A tendency to ulceration or papillary outgrowth 
is suspicious in a senile wart ; and the presence of an indurated base, and any trace 
of a hard, waxy, shining border with dilated vessels running over it, is conclusive as 
to the presence of carcinomatous degeneration. 

Prognosis. — Ordinary warts are important only from a cosmetic point of view ; 
they do not return if their bases are thoroughly destroyed after removal. The 
senile warts are of importance in that they are not infrequently the starting-point of 
cutaneous cancer. 

No. 129. Sublimate Collodion. 

IJs Hydrarg. chlor. corr. . . i part 
Collod. flexile . . .10 parts 

Treatment. — This is entirely local. Various means may be employed ; but care 
must be taken in their selection not to cause unnecessary destruction of tissue. I 
prefer electrolysis, the base of the wart being punctured in various directions with a 
fine needle connected with the negative pole of the galvanic battery, and a current 
of 1 to 4 milliamperes being passed through it for a few minutes. If care is taken 
to transfix and destroy the base of the growth, the wart drops off in a few days, 
leaving only a reddened surface and hardly any scar behind. (See p. 49.) The 
growths may be cut off with the scissors, or scraped out with the sharp curette, their 
bases being afterward cauterized with nitric acid, the acid nitrate of mercury, or 
pure carbolic acid. The galvanocautery or the Paquelin may also be employed. 
Even these minor surgical procedures are often unnecessary. Painting the wart 
repeatedly with sublimate collodion (No. 129, p. 251) will cause it to drop off. The 
20- to40-per-cent. salicylic-acid plaster-mull, the salicylic-cannabis collodion (No. 127, 
p. 245), or the salicylic-acid ointment (No. 124, p. 243) will destroy the epithelial coat- 
ing, and the bases of the growths can then be cauterized with chromic or other acid. 



2. HYPERTROPHY OF THE CONNECTIVE TISSUE. 

Under this heading we shall consider only elephantiasis Arabum, a malady 
formerly confounded with leprosy. 

ELEPHANTIASIS. 

Synonyms. — Elephantiasis Arabum, pachydermia, Barbados or elephant leg, 
elephantiasis (Fr.). 

Definition. — A chronic localized hypertrophy of the skin and subcutis, caused 
by circulatory disturbances due to repeated attacks of inflammation or to embolism 
by the Filaria sanguinis or its ova, and appearing as enlarged, thickened, indurated, 
and pigmented areas of skin. 



252 ILLUSTRATED SKIN DISEASES. 

Elephantiasis Graecorum is leprosy ; and naevus and other conditions often called 
elephantiasis belong under angioma, lymphangioma, fibroma, etc. 

Symptoms and Course. — Elephantiasis begins with a series of inflammatory or 
erysipeloid attacks, usually affecting the entire integument of an extremity, and 
commencing in a local lesion, a wound, or a scar, or in apparently healthy tissue. 
Lymphangitis and phlebitis are frequent concomitants ; the lymphatic vessels become 
thickened and hardened, and the lymphatic glands swollen and tender. The attacks 
occur at irregular intervals; and each one leaves the skin somewhat more swollen, 
and the vessels and glands somewhat larger and harder. After months or years 
they cease to occur, and the morbid process stops ; but the patient is left with a 
permanently deformed part, in which all the tissues of the skin are hypertrophied, 
and in which the fasciae and muscles, and even the underlying bones, may be 
affected. The enlargement is often enormous; the integument is rugose and warty 
(elephantiasis verrucosa, tuberosa, papillosa), or smooth and shiny (elephantiasis 
glabra). The enlarged lymphatics not infrequently rupture, and a permanent tric- 
kling of the fluid, a lymphorrhea, is set up; and eczema and ulcerations of varying 
depth not infrequently complicate the process. 

The commonest location of the disease is on the legs, and not infrequently one 
limb is affected alone or more severely than the other. The entire extremity is 
more or less swollen from the sole of the foot to the middle of the thigh, the natural 
contours are obliterated, and the surface is covered with irregular masses of indu- 
rated tissue firmly bound down to the subjacent parts. The integument may be 
dry and shining ; but, as more or less epidermic hypertrophy usually accompanies 
the process, it is often deeply pigmented, scaly, and covered with seborrheal and 
epithelial detritus. Most often, however, the surface is dry, horny, and irregularly 
tuberculated, with a foul secretion in the interstices of the wart}' excrescences. 
Excoriations, dirty-based ulcerations, and eczematous processes are usually present 
to a greater or less extent. The skin may be I to 2 inches thick, and the underly- 
ing tissues may be hypertrophied even to the bones. 

Elephantiasis of the genitals is less common. The scrotum may attain an 
enormous size and the penis disappear entirely in a funnel-shaped orifice. Alpin 
and Larrey record a case in which this organ weighed 120 pounds, and others have 
been noted in which the tumor reached below the knees and even to the ankles. 
In the female the labia are most often affected, and the ostium vaginae and the 
clitoris are obliterated. The skin over these tumors is usually rough, hard, and 
tuberculated, and more or less deeply pigmented. In other locations the disease is 
very rare, though it has been seen on the upper extremities and on the ears. 

Elephantiasis usually begins in adult life, and has rarely been seen in children. 
The subjective symptoms are not marked. The inflammatory attacks are painful, 
and later there is permanent discomfort from the tightness and "dead" feeling of 
the skin. In advanced cases locomotion is interfered with or rendered impossible, 




TYPOGRAVURf. 



COPYRIGHT BY E. B. TRFAT & CO. , N. Y. 



ELEPHANTIASIS ARABUM 



PLATE XXXVill. 



HYPERTROPHIES. 



253 



and not the least of the sufferings of the patients affected with elephantiasis of the 
genitals is the fact that it prevents the gratification of the sexual appetite. The 
malady is common in the tropics, but occasional cases are seen here. 

Etiology. — Chronic lymphatic stasis is the immediate factor that causes the de- 
velopment of elephantiasis, and the obstruction may be due to a variety of causes. 
Long-standing inflammatory pro- 
cesses affecting the lymphatic 
glands and leading to connective- 
tissue hyperplasia, and inflamma- 
tory affections of the skin, eczemas, 
erysipelas, syphilitic and lupoid 
ulcerations, together with the pres- 
sure of tumors and cicatrices, are 
the causes of the sporadic cases 
met with in the temperate zones. 
The cases that occur endemically 
in the tropics have been proved by 
Manson, Silva Araujo, Cobbold, 
and others to be due to the pres- 
ence in the fluids of the body of the 
Filaria sanguinis hominis and its 
embryos. These are readily found 
in the chylous urine and the lymph, 
but swarm in the blood only in the 
night-time. During that time they 
are absorbed by the mosquitos, in 
whose bodies they pass the inter- 
mediate stage of their existence. 
In about three days the insects die, 
and, by bathing, or through the 
drinking-water, are taken into the 
human body again. The presence 
of the parasite and its embryos in 

the lymph-channels and -glands obstructs the lymphatic flow and leads to the hyper- 
trophy. 

Pathology. — The lymphatic vessels and the veins are enormously dilated, and 
the tissues are saturated with lymph. All the elements of the skin are more or less 
hypertrophied from the presence of new connective tissue, but the greatest change 
is in the subcutis. Even the muscles are enlarged, and the bones show new osteo- 
phyte growth. All the glandular structures are more or less atrophied. 

Diagnosis. — This is readily made from the enormous enlargement of the part, 




Fig. 126. — Elephantiasis vulvas. 
After Van Haren-Noman. 



254 ILLUSTRATED SKIN DISEASES. 

' the firm oedema, the papillary outgrowths, lymphorrhea, etc., and there is no other 
malady with which it is liable to be confounded. 

Prognosis. — The prognosis as to cure is bad, though the malady does not endan- 
ger life. The interference with motility and work is very serious. The difficulties 
of sexual congress when the genitals are affected have already been adverted to. 
Treatment. — Prophylaxis consists in the treatment and cure of all conditions 

"causing venous and lymphatic stasis of the lower limbs or genitals, eczema, simple 
or specific ulcerations, lupus, etc., and the removal of mechanical obstructions, scars, 
tumors, etc., to the lymphatic flow. The direct treatment of the condition is not 
hopeful, since neither local measures nor internal remedies will remove the new- 
formed connective tissue. Rest in bed, with elevation of the limb, together with 

;the use of rubber or other bandages, may do good in the beginning. In advanced 
cases excision of the hypertrophied tissues or amputation of the part may be ad- 
visable ; but the course of the wound is a very uncertain one. Other measures, such 

■as the ligation of arteries, the excision of nerves, the use of galvanism, etc., have 
given no satisfactory results. 



3. HYPERTROPHY OF THE SEBACEOUS GLANDS. 

This hardly occurs as a distinct affection. We include molluscum contagiosum 
under this heading; for though it is probably not a sebaceous-gland hypertrophy, as 
was formerly supposed, it is best considered here. 

MOLLUSCUM CONTAGIOSUM. 

j|fe Synonyms. — Molluscum sebaceum, epithelioma molluscum, acne varioliformis 

Definition. — An affection characterized by the appearance on the skin of small, 
semi-transparent, flesh-colored, wart-like or globular, umbilicated tumors. 

Symptoms and Course. — Molluscum contagiosum begins with the appearance of 
one or more minute, slightly prominent, transparent, shining whitish nodules, which 
slowly grow into pea-sized or larger sessile or pedunculated tumors. Their surface 
is usually smooth; their color is that of the normal skin, the stretching of the epider- 
mis over their tops giving them a faint whitish, waxy glance ; and they are some- 
times situated on slightly reddened bases, though the skin around them is perfectly 
normal. Their flattened summits are marked with a slight but distinct depression, 
to which is due the French designation of the disease ; and in the center of this the 
■small opening into the mass can almost always be seen. Though moderately firm 
to the touch, their contents can be expelled by pressure, and form a greasy or tal- 
low-like mass containing the peculiar bodies known as molluscum corpuscles. The 



HYPERTROPHIES. 



255 



tumors grow very slowly and may be present for months or years. They may 
disappear spontaneously in time, or be destroyed by inflammatory processes, sup- 
puration, or ulceration. They may be single, but are usually multiple, and in some 
cases large numbers are present. 
Their commonest seat is upon the 
face, and next commonest upon the 
genitals and hands; but they are 
occasionally found on other portions 
of the body. The malady is com- 
moner in children than among adults. 

Etiology. — The molluscum cor- 
puscles are oval- or lemon-shaped 
bodies which have been identified 
by some observers with parasites 
belonging to the Coccidia subclass 
of the Sporozoa (Bollinger and Neis- 
ser), but are regarded by others as 
peculiarly modified and swollen rete- 
cells (Lesser, Israel, Kromayer, etc.). 
The facts that several cases some- 
times occur in one family, that parts 
that are liable to be brought in con- 
tact are their usual seat, as well as 
the direct and successful inoculation 
experiments of Haab and Pick, suffi- 
ciently demonstrate their contagious 
nature. 

Pathology. — The tumors are 
composed of densely packed lobular masses containing epithelial detritus, fat-glob- 
ules and -crystals, and the above-mentioned peculiar corpuscles. It is a question 
whether the lobules are the remains of sebaceous glands or not, for the process seems 
to start in the rete. 

Diagnosis. — The tumors situated on normal non-inflamed skin, with central de- 
pressions and expressible, semi-solid contents, and containing the molluscum corpus- 
cles, are characteristic. In milium the nodules are small and flat, yellowish white 
or brown in color, with no central opening and with tallowy contents. Fibroma 
molluscum is a solid new growth, with no central opening and no expressible contents, 
and resembles the contagious molluscum only in its name. In variola the fluid con- 
tents of the vesicles and the fever and course of the disease will prevent mistake. 

Prognosis. — This is invariably good ; the tumors may end spontaneously, and in 
any case they can be readily removed. 




Fig. 127. — Molluscum contagiosum. 
From photograph by the author. 



L 



256 ILLUSTRATED SKIN DISEASES. 

Treatment. — Mollusca are readily removed by expression, more especially after 
an incision has been made to facilitate the extrusion of the mass. The curette may 
also be employed. It is not necessary to cauterize the sac. 

4. HYPERTROPHY OF THE HAIRS. 

This may be quantitative, an increase in number, or qualitative, an increase in 
size or length of the appendages. Both conditions may be considered under the next 
heading. 

HYPERTRICHOSIS. 

Synonyms. — Hirsuties, hypertrichiasis, polytrichia. 

Definition. — An increase in the size or the amount of the hair, or its growth in 
unusual locations. 

Symptoms and Course. — An abnormal growth of the hair occurs only where hair- 
follicles are normally present, and is never seen on the palms and soles, the dorsal 
surfaces of the terminal phalanges, or on the lips. Excessive length and thickness 
of the stiff hair in normal situations is not uncommon. Beigel records one case 
where the hair was 9 feet long, and Leonard one where the beard measured 7 feet. 
Similar growth of the hair of the eyebrows, pubes, and axillae, as well as of that on 
the trunk and limbs of males, is often seen. A hairy growth, normal in the male, 
becomes hirsuties in the female, and is usually associated with some disorder of the 
generative organs. Examples of bearded women are exhibited as curiosities; and 
I have had one under my care whose beard was heavier than that of the average 
man, and whose husband shaved her daily. Females occasionally have hair on the 
breast or around the nipple, and a line of hair extending from the pubes to the 
umbilicus, as in the male. In both sexes long hair is occasionally found in locations 
usually covered only with the fine down of the lanugo, as the small of the back and 
the extensor surfaces of the limbs. Cases in which the normal hairy growth appears 
too early on the face and around the genitals are usually accompanied by preco- 
cious sexual development. Beigel has recorded one of a girl of six, whose pubic hair 
was as long and vigorous as that of an adult. Again, hirsuties frequently occurs on 
the chin of females after the menopause. Irritation, as from blistering, the use of 
stimulating applications, the pressure of bandages, may cause similar local hyper- 
trichosis. 

Unusual growth of the fine lanugo hair that covers the surface of the body 
almost everywhere occurs in cases of universal hirsuties. Such were the well-known 
Shwe-Maon family, in which the anomaly was observed by Beigel and -Crawford 
during three generations, and the Russian Andrian Leftichjew. Here the downy 
hair develops into a soft brown or blond growth an inch or more in length, usually 



HYPERTROPHIES. 257 

most pronounced upon the face. Deficient development of the teeth is present in 
most of these cases. 

Etiology. — General hypertrichosis of the lanugo hair is usually hereditary, and 
is to be regarded as a defect of development, and a persistence of the fetal hair that 
is usually shed before or soon after birth. The same condition of the ordinary hair 
is generally a race or family characteristic, and is commoner in persons of dark com- 
plexions. Partial hypertrichosis may be caused by the increased nutrition due to 
the long determination of blood to a part, as by the persistent use of sinapisms, lini- 
ments, etc., or by perverted, precocious, or arrested activity of the sexual functions. 
The hirsuties of the lumbar and dorsal regions is sometimes connected with a con- 
cealed spina bifida. In many cases, however, the cause of the hypertrichosis is 
entirely obscure. 

Pathology. — The abnormal growth does not differ in structure from that of the 
ordinary amount and in the usual situations. 

Diagnosis. — Hairy naevi may be confounded with localized hypertrichoses ; but 
the unchanged texture and color of the skin should readily distinguish them from 
the latter, which are usually pigmented and hypertrophic. 

Prognosis. — The abnormal hairs are readily removed temporarily. Permanent 
removal depends on the possibility of the destruction of the hair-papillae, and this, 
being very slow and troublesome, cannot be done where very large surfaces of the 
skin are affected, or where there is a general overgrowth of the lanugo hair. I 
have, however, removed over 14,000 hairs from the face of a woman in the course 
of two years, with a finally satisfactory result. 

No. J30. Duhring's Depilatory. 

R Barii sulphidi ... 2 parts 

Pulv. zinci ox. 
Pulv. amyli . . . aa. 3 " 

Treatment. — Extraction with the forceps is not much better than shaving; the 
papillae are left behind, and the hairs grow again in a short time. The same may 
be said of depilatories, though they do destroy the shaft of the hair down to its neck. 
Perhaps the best of them is the combination recommended by Duhring (No. 130, 
p. 257). It should be made into a thin paste with water, applied for ten or fifteen 
minutes, and scraped off as soon as burning is felt, and cold cream applied. Those 
containing arsenic are dangerous, and they all stimulate the growth of the lanugo 
hair more or less. The only radical and satisfactory treatment is by electrolysis, 
which we owe to Michel and Hardaway, of St. Louis. The method will be found 
described in detail on page 49. Much patience is required if the growth is at all 
extensive. The operation is uncomfortable, but not really painful, and a 20-per- 
cent, cocaine-adeps lanae ointment may be applied before the electrolysis, to mitigate 



258 



ILLUSTRATED SKIN DISEASES. 



it. Removal of lanugo hairs should never be attempted ; the remaining hairs are 
inevitably stimulated in their growth by the irritation caused by the current, and the 
patient's last condition is worse than the first. 

5. HYPERTROPHY OF THE NAILS. 

One affection only, onychauxis, is to be considered under this heading. 



ONYCHAUXIS. 

Synonym. — Onychogryphosis. 

Definition. — An increase in the size or the thickness, or both, of the nail. 

Symptoms and Course. — Hypertrophic nails may be of normal thickness and 
texture, and be simply increased in length up to 3 inches or more. Or they 

may be broad and thick, tend to split 
in a lamellar manner, and, by their 
pressure on the neighboring soft parts, 
be the cause of paronychia. Or again, 
they may be bent and curved in vari- 
ous directions, and often in a spiral 
shape ; which latter condition is more 
correctly called onychogryphosis. The 
nails lose their luster, become rough, 
furrowed, fissured, and of a blackish- 
or brownish-gray color. Increase in 
size of the nails also occurs during the 
course of various diseases, eczema, 
psoriasis, lepra, syphilis, etc. (pp. 200, 
217). Onychauxis occurs most often 
in the toe-nails, and is rarely seen upon 
the hands. 

Etiology. — These conditions are 
sometimes congenital; but they are 
more commonly seen in elderly per- 
sons, in the bedridden, and in other 
cases where proper care is not taken 
of the nails. The pressure of improper 
footwear is a potent cause of the 
affection. 

Pathology. — The papillary body of the nail-bed is hypertrophied, but there is 
probably a change in quality as well as in quantity of the epidermic cells. 




Fig. 128. — Onychauxis 

After Van Haren-Xoman. 




COPYRIGHT, BY E. B. TREAT & CO. , N. Y. 



PHOTOGRAVURE 4 COLOR CO., N. Y. 



NAEVUS PIGMENTOSUS 



PLATE XXXIV. 



Treatment. — Frequent < i 
of appropriate footwear, is the 
Inflammation of the matrix, and or 
only a symptom, must be approprkr 
be softened in hot water, and then cut < 
cylic-acid ointment (No. 124 



use 



6. HYPERTROPHY Ol 

Excessive pigmentation 
coloring-matters; and this ■■'■ 
rus, and argyria, or local, as in tattoo-mark 
from dyes, acids, etc. Hyp 

circumscribed and is often and under me naevus 

mentosus,- lentigo, ephelis, an 



N#/v GMENTOSUS. 



Synonyms.— Pigmenta; 
(Ger.), tache pigmentairc (Fr.). 

Definition. — A congenital ci 
with or without increase oi 
tissue and the hairs. 

Symptoms and Course.- 
as a single spot, or a-^ many 
small, even pinhead in size 
Their shape is oval, circular 
shade from light-yellow br 
pearing spontaneously 
is an increase in size with 
tribution follows the course 

iave them. 

In accordance with th 
elements of 

ture and functio 

are shari 
where on the b 
face, the ne<- 
trophy of t; 









: 

■ 

ns. Thes 

1 any 

■i'ormities, disap- 

eiopment 

>nally their dis- 

Both sexes are equally liable 

■ 

be noted. In 

is unaltered in tex- 

-pots 

yellow to lark-bro\ They occur' any- 

n the mui ut are most frequently seen U] 

cs of the hands. In naevus veri 

discolor. ,d or in 




COPYRIGHT. 6V 



. 






HYPERTROPHIES. 259 

Treatment. — Frequent cutting and proper care of the nails, together with the use 
of appropriate footwear, is the best treatment, both prophylactic and curative. 
Inflammation of the matrix, and other skin affections, of which the onychauxis is 
only a symptom, must be appropriately treated. The exuberant horny growth can 
be softened in hot water, and then cut or scraped away ; or be treated with the sali- 
cylic-acid ointment (No. 124, p. 243) increased to a strength of 1 to 10. 

6. HYPERTROPHY OF THE PIGMENT. 

Excessive pigmentation of the skin may occur from the deposition in it of foreign 
coloring-matters; and this deposition may be general, as in Addison's disease, icte- 
rus, and argyria, or local, as in tattoo-marks and the various stainings of the skin 
from dyes, acids, etc. Hypertrophy of the normal pigment of the skin is always 
circumscribed and is often congenital ; and under that heading come naevus pig- 
mentosus, lentigo, ephelis, and chloasma. 

NiEVUS PIGMENTOSUM 

Synonyms. — Pigmentary naevus or mole, Fleckenmal, Pigmentmal, Muttermal 
(Ger.), tache pigmentaire (Fr.). 

Definition. — A congenital circumscribed hypertrophy of the pigment of the skin, 
with or without increase of its other elements, most commonly of the connective 
tissue and the hairs. 

Symptoms and Course. — The deposit of pigment is congenital, and may appear 
as a single spot, or as many, even hundreds, of discolorations. These may be very 
small, even pinhead in size, or so large as to occupy extensive areas of the body. 
Their shape is oval, circular, or irregular. Their color varies greatly, being of any 
shade from light-yellow brown to black. They are permanent deformities, disap- 
pearing spontaneously only in very exceptional cases ; and their only development 
is an increase in size with the general growth of the skin. Occasionally their dis- 
tribution follows the course of the cutaneous nerves. Both sexes are equally liable 
to have them. 

In accordance with the presence or absence of coincident hypertrophy of other 
elements of the skin, several varieties of pigmentary naevus are to be noted. In 
naevus spilus the skin is smooth and, save for the discoloration, is unaltered in tex- 
ture and function; the round or irregular, small or large, few or numerous spots 
are sharply limited, and of a yellow to dark-brown or black color. They occur any- 
where on the body, even on the mucosae, but are most frequently seen upon the 
face, the neck, and the backs of the hands. In naevus verrucosus there is hyper- 
trophy of the papillae in addition to the discoloration, giving us round or irregular, 



i2»;o 



ILLUSTRATED SKIN DISEASES. 




various-sized, warty, and pigmented masses. Epidermal proliferation and scaling 
and increased sebaceous secretion are often present. In naevus pilosus the hyper- 
trophied area, whether smooth or rough, is more or less covered with coarse lanugo 

or longer hairs. Extensive naevi of this variety, 
covering large surfaces of the body, and causing 
the skin to resemble the hide of an animal, have 
been reported. The color of the smooth or warty 
skin varies, as does that of the hair upon it ; and 
verrucas, fibromata, and lipomata are often present 
either in the area of the naevus or outside it. As 
is the case in general hypertrichosis, congenital 
defects of the teeth are often found in conjunction 
with these deformities. In naevus lipomatodes s. 
mollusciformis there are elevations and projections 
— tumors of fatty or connective tissue of varying 
size and shape — in the pigmented area. Some 
cases of extensive naevi are unilateral, or follow 
the tracks of the nerves, and are described as naevus 
unius lateris, Xcrvcnncevi (Ger. ). 

Etiology. — There is no scientific foundation 
for the belief that maternal impressions have any- 
thing to do with the appearance of naevi. The 
condition is hereditary in some instances ; but 
we are ignorant of its real cause. 

Pathology. — In naevus spilus there is simply an accumulation of pigment in the 
rete and the upper layers of the corium. In all the other forms there is in addition 
hypertrophy of the corium, more especially of the papillae, of the epidermis, and of 
the glandular structures of the skin. 

Prognosis. — This is good as to life and health, though occasionally naevi form 
the starting-point of sarcoma and carcinoma later on. The possibility of removal 
depends, of course, on the site and the extent of the deformity. 

Treatment. — No attempt should be made to treat very extensive pigmentary 
naevi either of the smooth or the warty and hairy varieties ; for, apart from the 
difficulties and length of time that is required, the cicatricial tissue may be more 
deforming than the original lesion. Circumscribed smooth naevi may be treated 
with trichloracetic acid, carefully applied to the part by means of a glass rod at 
intervals of a few days, or with the sublimate collodion (No. 129, p. 251). But for 
these, as for the smaller hairy and warty naevi, electrolysis is usually the most suit- 
able and efficacious means of treatment. The process is similar to that for epilation of 
the hairs (p. 49), but a somewhat coarse needle may be employed. If the pigment 
deposit is superficial, the needle should be passed in obliquely under the epidermis, 



Fig. 129. — Xtevus pigmentosus. 

From photograph by the author. 



HYPERTROPHIES. 261 

so as to " blister the spot," as Fox terms it. Larger growths may be curetted, or 
destroyed with the Paquelin, and an iodoform dressing applied. For the mollus- 
coid forms the knife or the galvanocaustic snare offers the only means of relief. 



LENTIGO. 

Synonyms. — Ephelides, freckles, Linsenflecke, Sommersprossen (Ger.), taches de 
rousseur (Fr.). 

Definition. — Small, circumscribed deposits of pigment, appearing as spots or 
patches, and most commonly seen on the face and the backs of the hands. 

Symptoms and Course. — Freckles are never congenital, and rarely appear before 
the second decade of life. They are pinhead- to pea-sized discolorations, varying 
in tint from a salmon yellow through brown to a sepia black. Their form is 
rounded, oval, polygonal, or irregular, and they are never elevated above the surface 
of the skin. Their usual site is upon the face, especially the cheeks and nose, and 
on the backs of the hands. In rare instances they have been seen on other and 
covered parts of the body. There may be few or many, and the patches may be 
isolated or confluent; and in extensive and deeply colored cases the deformity is 
considerable. Both sexes are equally liable to them ; but they occur most com- 
monly in individuals of light complexion and with red or auburn hair. Mulattos 
are very much subject to them, as they are to other pigment anomalies. They 
grow darker in summer, and fade, but do not entirely disappear, in the winter. 

Etiology. — Heredity has some influence here, as with other pigmentations. The 
sun's rays, more especially the ultra-violet ones, cause their appearance and exten- 
sion; but a congenital predisposition to their appearance is also necessary. 

Pathology. — A freckle is a collection of pigment granules in a circumscribed 
group of rete-cells, and it differs from chloasma only in the shape and size of the 
affected area. 

Prognosis. — Freckles may be removed, but they are almost certain to return 
upon renewed exposure to sunlight. 

No. J3J. Bulklefs Lotion. 



fy Hydrarg. chlor. corr. . 


. 


3 parts 


Boracis 


. 


20 " 


Acid, acetic, dil. 


. 


60 " 


Aq. ros. 


. ' 


500 



Treatment. — This is in general that of chloasma and other pigment accumula- 
tions. Any agent that will cause inflammation and subsequent desquamation of the 
epidermis will remove them for the time being. I have found 1 : 500 sublimate 
compresses, allowed to remain in situ for three or four hours, efficacious; but the 



262 ILLUSTRATED SKIN DISEASES. 

patient should be warned beforehand of the swelling and redness that will ensue. 
Bulkley recommends sublimate and acetic acid (No. 13 1, p. 261) to be brushed over 
or rubbed into the affected areas night and morning. 

CHLOASMA. 

Synonyms, — Liver-spot, masque de la grossesse (Fr.). 

Definition. — An abnormal deposit of pigment in the skin, appearing as a smooth, 
yellow-brown to blackish, circumscribed or diffuse discolored patch. 

Symptoms and Course. — The pigmentation of chloasma may be sharply limited, 
or it may be diffuse and shade gradually into the color of the normal skin. Its 
shape may be circular, oval, or irregular; and its size varies from that of a thumb- 
nail up. Its color may be so light a yellowish brown as to be barely perceptible ; 
or it may be darker brown or even blackish, and is then called melanoderma. It 
may be due to external agents and local affections of the skin, or it may be caused 
by derangements of the internal organs and by general diseases. Chloasma calori- 
cum is the tanning of the skin that is caused by exposure to the rays of the sun. 
It soon fades away when its cause is removed. Chloasma traumaticum is caused by 
the local action of external agents upon the skin, or follows the lesions of various 
dermal affections, and appears as a diffuse or circumscribed discoloration which lasts 
for a long time or is permanent. Chloasma symptomaticum s. uterinum appears in 
conjunction with abnormalities, derangements, or diseases of the uterine organs, and 
forms a diffuse or well-defined spot or patch of varying shade, oftenest situated on 
the forehead, the sides of the nose, cheeks, and neck. It usually disappears when 
its cause its removed. 

Etiology. — An excessive deposition of the natural pigment in the skin may be 
due to external or to internal causes. Any chemical, mechanical, or thermic irri- 
tant that causes long-standing hyperemia of the skin may occasion its appearance. 
Such are the long-continued use of counter-irritants, vesicants, and plasters, expo- 
sure to sunlight, the pressure of clothing, apparatus, etc. Similar discolorations 
accompany or follow certain dermal affections. After the erythematous lesions the 
discoloration is fugitive; but that following lichen planus, the syphilodermata, etc., 
is darker and more persistent. More diffuse pigmentations may follow all the itch- 
ing skin diseases, eczema, phtheiriasis, prurigo, etc., and is due to the deposit of 
blood-pigment in the skin from the lesions caused by scratching. 

Internal causes may be various affections of the system and of special organs; 
least commonly, however, in spite of the popular name of the deformity, diseases of the 
liver. Diffuse discolorations occur with cancer and phthisis. Most often by far, how- 
ever, they occur in connection with affections of the uterine tract, functional dis- 
orders, sterility, amenorrhea, displacements, tumors, ovarian disease, etc., and they are 
found with especial frequency in gravidity. There is a well-established relationship 



HYPERTROPHIES. 263 

between these conditions and the pigment deposits, and the latter disappear when 
the former are relieved ; but we are ignorant of the reasons for it. 

Pathology. — The skin is entirely unaltered in chloasma, save for the excessive 
deposit of pigment granules in the rete. 

Diagnosis. — The unaltered condition of the skin, save for the pigmentation that 
does not disappear under pressure, and the entire absence of inflammatory appear- 
ances and subjective sensations, are characteristic. Chloasma and chromophytosis 
might be confounded; but the slight furfuraceous desquamation and the demon- 
stration of the etiological agent under the microscope will always enable us to dis- 
tinguish the parasitic disease. 

Prognosis. — This is uncertain. We may be able to remove the spots, but they 
are very liable to return. The means employed for their eradication are necessarily 
such as are liable themselves to cause pigmentation of the skin. 

Treatment. — This consists in the first place in the removal of the cause, when 
such can be ascertained to exist. Locally, the old pigmented epithelial cells must 
be removed. This is best done by means of bichloride compresses, I to iooo or 
500, allowed to remain on for several hours, until inflammation and vesiculation 
occur; the parts are then to be dressed with a mild dusting powder or ointment 
(No. 18, p. 61, No. 26, p. 70, Nos. 68, 69, p. 135). Bulkley's lotion (No. 131, p. 26 1) 
or citric acid in watery solution of a strength of I to 16 may be used in a similar 
way. Touching the spots with pure carbolic acid has done well in some cases. 
Salicylic acid, in ointment, paste, or plaster (No. 79, p. 153, No. 124, p. 243), is an 
efficient agent to remove the superficial epidermic layers. It is a safe application, 
and should always be tried before more active agents are used. We must never 
lose sight of the fact, however, that all these agents are themselves liable to cause 
pigmentation of the skin. 



CLASS V. 
NEW GROWTHS. 



Under this heading we classify a number of dermal changes that consist essen- 
tially in the growth and infiltration of the skin with new elements, and usually appear- 
ing as tumors. They may be homologous or heterologous, benign or malignant. The 
new elements are of connective tissue in cicatrix, keloid, fibroma, myxoma, neuroma, 
lipoma, xanthoma, and sarcoma; of muscular tissue in myoma; of vascular tissue 
in angioma and lymphangioma; and of epithelial tissue in adenoma and carcinoma. 



U NEW GROWTHS OF CONNECTIVE TISSUE. 

CICATRIX. 

Cicatrix, scar, Narbe (Ger.), is a dense, smooth, attached or movable, connective- 
tissue new growth covered with epithelium, which replaces the normal elements and 
glandular structures of the skin where the connective tissue of that organ has been 
destroyed by traumatic, ulcerative, or necrotic processes. It occurs after destructive 
injuries and after the various inflammatory diseases, as acne, variola, zoster, ecthyma, 
lupus, syphilis, dermatitis, etc. It forms an important secondary lesion of the skin, 
and as such its chief characteristics have already been described (p. 38). Scars are 
usually atrophic, and cause deformity and disability by the traction that they exert 
and the loss of motion that they occasion. They are sometimes hypertrophic ; but as 
there is no practical distinction to be made between this condition and spontaneous 
keloid, the hypertrophic scar will be considered in connection with that subject. 

The kind of scar resulting from any one of the above-mentioned processes 
depends upon the course of the granulations from which the new connective tissue 
develops, and it is therefore necessary to watch the granulation process and control its 
growth. Either excessive or deficient granulation will prevent cicatrization and the 

264 





LYMPHANGIOMA. 



VITILIGO. 





TVPO&RAVURE. 



KELOID. 



COPYRIGHT, 1903, BV E. B. TREAT 4 CO. , N. Y. 

FIBROMATA. 



PLATE XL. 



NEW GROWTHS. 265 

formation of the epithelial covering that terminates the process ; for both can only 
occur when the granulations are just on a level with the surrounding skin. Deficient 
granulations must be stimulated with camphor, iodoform, or the nitrate of silver in 
1- to2-per-cent. solution. Exuberant granulations must be repressed with the nitrate- 
of-silver stick, straps of adhesive plaster, or compresses soaked in alcohol. The 
treatment of scars after their formation is simple when the surrounding tissues are 
lax and elastic enough to permit of their excision and replacement by a simple linear 
cicatrix. Where this is not the case, scarification (p. 50) offers the best chances of 
improvement, though electrolysis and galvanopuncture may also be tried. All 
these measures should be followed by the persistent use of the mercurial plaster. 
Baths, douches, and massage may be employed to soften scars and render them 
elastic. 

KELOID. 

Synonyms. — Cheloid, Narbenkrebs, Knollenkrebs (Ger.). 

Definition. — A benign connective-tissue new growth of the skin, characterized 
by the appearance of raised, variously shaped and sized, smooth, elastic, white or 
pinkish tumors, occurring after injuries to the cutis or spontaneously. ■ 

Symptoms and Course. — Keloid begins as a small, pale, pea-sized nodule which 
gradually grows into a sharply circumscribed, dense, elevated tumor which may 
occupy an area of several square inches. Its shape may be circular, oval, elongated, 
or irregular; and in many cases it consists of a central mass with projecting arms, 
which gives to the growth a crab-like appearance. Its color is white or pinkish ; it 
is hard but elastic to the touch ; and its surface is covered with a thin epidermis in 
which sweat-glands are present, but no hairs and sebaceous glands are to be found. 
A single tumor, or many, may be present. De Amicis records a case that had three 
hundred and eighteen of these neoplasms. Keloids grow very slowly, and, having 
attained a certain size, usually remain unchanged for life. In exceptional cases they 
undergo retrogressive changes and disappear, and sometimes they develop into epi- 
theliomata. Their commonest seat is upon the sternum, but they are also found 
upon the face, trunk, and extremities. The subjective symptoms that they occa- 
sion are limited to slight pain and tenderness on pressure. 

Two varieties of keloid are to be distinguished. The false or cicatricial keloid is 
often single, and here the new growth develops from the scars of any of the dermal 
affections that are accompanied by loss of tissue, — acne, zoster, variola, syphilis, etc., 
— from traumatisms, and with especial frequency from burns. The shape, size, num- 
ber, and location of the keloids will depend largely upon the characters of the origi- 
nal scars. They may be distinguished from the simple hypertrophic scar by the 
fact that the connective-tissue new growth extends beyond the limits of the original 
lesion. The true keloid develops in the normal connective tissue of the skin with- 
out antecedent cicatrix formation. As, however, we necessarily depend on the 



266 



ILLUSTRATED SKIN DISEASES. 



history of the patient for information upon this subject, it must always remain a 
matter of doubt ; and it is possible that spontaneous keloid may have developed at 
the site of pressure, contusions, or small and forgotten lesions of the skin. 

Etiology. — This is really unknown. Family predisposition may have some 
influence, and syphilitic scars and those produced by burns seem especially prone to 

become keloidal. The very young and the 
aged are rarely affected. The colored races 
seem more prone to the disease than other 
people. Many apparently spontaneous cases 
follow the slight lesions of acne, varicella, 
herpes, etc. 

Pathology. — The keloidal tumor is com- 
posed of bundles and masses of connective 
tissue imbedded in the skin. In the false 
form the new tissue is irregularly disposed, 
and the papilla; of the skin are destroyed. 
In the true form the dense connective-tissue 
bundles are horizontally arranged in the 
corium, and the rete and papillae are intact. 
Diagnosis. — The hard, elastic, elevated, 
permanent, scar-like, and usually insensitive 
tumors are quite characteristic. The hyper- 
trophied cicatrix is to be distinguished from 
keloid by its exact limitation to the site of 
the original lesion ; and this is a matter of 
some importance, since the operative inter- 
ference that might be proper in the one 
case is useless or even hurtful in the other. 
Prognosis. — This is very doubtful so far 
as the removal of the tumors is concerned. 
They frequently resist all ordinary measures, and are very prone to recur after re- 
moval. 

Treatment. — This should only be undertaken when, for cosmetic or other rea- 
sons, it is very desirable to remove the tumors. Treatment by excision or destruc- 
tion with the cautery is very unsatisfactory, as the tumor is almost certain to return 
in the scar. Multiple scarification, cross-hatching the tumor with a bistoury or the 
scarificator (Fig. 15, p. 50), the incisions being deep enough to entirely divide the 
growth, is the most promising course of treatment to pursue. This should be done 
once a week, the mercurial plaster or the 20- to 50-per-cent. resorcin plaster being 
applied during the intervals. The process is not as painful as it seems, and I have 
obtained good results from it in one case. Electrolysis, as described for the de- 




Fig. 130.— Keloid. 

From photograph by the author. 



NEW GROWTHS. 267 



struction of hairs (p. 49), has been successfully employed, the needle being passed 
obliquely from the margins through the center of the growth. 



FIBROMA. 

Synonyms. — Fibroma molluscum, molluscum fibrosum, molluscum pendulum. 

Definition. — A connective-tissue new growth, characterized by the appearance 
in the skin of flat or pedunculated, rounded, painless, soft or firm tumors of varying 
size. 

Symptoms and Course. — True fibroma begins as a minute, circumscribed, nodular 
tumor deeply seated in the normal skin, and varying in consistency in accordance 
with the hardness of the connective tissue of which it is composed. It usually appears 
first in childhood, and may even be present at birth ; and it increases slowly but 
continuously up to a certain size, and then remains stationary and persists for life. 
When fully developed it forms a tumor that varies in size from that of a pea to a 
mass as large as a child's head and weighing many pounds. A single one may 
be present, but there are usually several of them ; often they are very numerous, 
and as many as three thousand have been counted in a single case. In shape 
they may be semiglobular, broad-based and adherent, or they may be project- 
ing, ball- or club-shaped, and pedunculated (molluscum pendulum). Their consis- 
tence may be soft, or firm and elastic. The skin over them is normal and loose or 
tense and reddened ; it may be hypertrophied or atrophic, and sometimes shows 
hairs and a few large comedones on its surface. Fibromata, when numerous, are 
usually most abundant upon the trunk; but the head and limbs are often affected. 
They are rare upon the palms and soles. In some cases fibroma appears as a single 
large, not distinctly circumscribed, and pendulous growth. Occasionally the growth 
of the tumors is rapid, and excoriation, ulceration, and even sloughing may occur. 
In very rare instances they finally undergo a sarcomatous or carcinomatous degen- 
eration. Save in these cases, however, the general health is not affected, and the 
patient suffers only from the cosmetic effects of the deformity, and the interference 
with his vocation when the tumors are very large and heavy or are situated on the 
face, and with sexual intercourse when they are upon the genitals. The malady 
occurs with equal frequency in both sexes, but it is very rare in this country. 

Etiology. — The cause of fibroma is unknown ; heredity has some influence, as is 
evidenced by the records of several cases in one family. 

Pathology. — In the softer fibromata the connective tissue is loosely arranged in 
alveoli, and is gelatinous and in a more or less imperfectly developed condition. 
The older and firmer tumors are more densely fibrous. 

Diagnosis. — The multiple hard or soft tumors, deep-seated or projecting, their 
stability and very slow course, and the entire absence of general and subjective 



• 



268 ILLUSTRATED SKIN DISEASES. 

symptoms, are characteristic. Molluscum contagiosum grows quickly, is very super- 
ficial, has a central depression and opening, and expressible, hyaline contents. 
Neuromata may be distinguished by their painfulness and sensitiveness. Lipoinata 
are soft and lobulated, and never pedunculated. 

Prognosis. — Fibromata are benign tumors, and rarely undergo inflammatory 
changes or carcinomatous or sarcomatous degeneration. Very exceptionally they 
undergo spontaneous involution. If few in number, they may be removed ; but we 
can do little for the cases in which they are numerous. 

Treatment. — Arsenic given persistently in full doses may be tried; but the only 
treatment that is at all hopeful of results is the surgical one, and that is applicable 
only to cases in which the tumors are not numerous. Excision, or destruction with 
the galvanocautery or the ecraseur, may be employed to remove the growths. 

MYXOMA. 

Myxoma is a rare affection of the skin, appearing first as a small subcutaneous 
nodule of a soft and jelly-like consistency, and rapidly increasing in size. The skin 
over it, at first normal and freely movable, becomes attached and reddened, and 
finally ulceration and perforation occur. It may appear anywhere, more especially 
where the panniculus adiposus is thick, and myxomatous tumors have been found 
on the back, shoulders, gluteal regions, thigh, and the labia majora. They may 
be single or multiple. They are composed of immature gelatinous connective tissue, 
and are not benign tumors ; for while metastasis and general infection are rare, they 
are apt to return in situ after operation. They are frequently mixed growths, myxo- 
fibromata, myxosarcomata, myxolipomata, etc., and then they partake more or less 
of the characteristics of the other tumor elements of which they are composed. The 
only treatment is excision. 

NEUROMA. 

Under the name of neuroma is described a very rare tumor of the skin which is 
in almost all cases a fibroma starting from the perineurium of the superficial nerves. 
It occurs in middle or advanced life, and appears as pinhead- to hazelnut-sized, 
round or oval, and usually multiple tubercles, seated in the skin of the shoulders, 
thighs, buttocks, etc. Their color is pinkish or purplish ; they are firmly seated in 
the corium ; and they are both tender and spontaneously painful. The nerve-struc- 
tures suffer only secondarily. The only treatment is excision. It is doubtful if 
tumors composed of true nerve-tissue occur in the skin. 

LIPOMA. 

A lipoma, adipoma, fatty tumor, Fettgeschwiilst (Ger.), is a circumscribed or 
diffuse cutaneous or subcutaneous tumor composed of fatty tissue. It forms a soft 





ELEPHANTIASIS 



SARCOMA PIGMENTOSA. 





TYPOGPAVURF. 



COPYRIGHT BY E. B. TREAT 4 CO., N. Y. 



SARCOMA CUTIS. 



TUBERCULOSIS CUTIS VERRUCOSA. 



PLATE XLVIII. 



NEW GROWTHS. 269 

lobulated mass of varying size ; occasional examples are iarge and weigh many- 
pounds. The superjacent skin is normal and movable, and, if the growth is large, 
may be distended and thinned (lipoma polyposum s. pendulum). Lipoma is a com- 
mon affection ; the tumors may be single or multiple ; as many as two hundred have 
been found by Weber in a single case. They may occur anywhere where fatty tis- 
sue exists, and are commonest on the back and shoulders. They are most often 
seen in females, and usually appear late in life. They are most often distinctly cir- 
cumscribed, but occasionally they form more diffuse and pendulous masses. They are 
benign tumors, and are not much subject to change ; but sometimes they retrogress 
spontaneously, or degenerate into a cheesy mass ; and, if they are very large, ulcer- 
ation may be occasioned by mechanical causes. The treatment is excision. 

XANTHOMA. 

Synonyms. — Xanthelasma, vitiligoidea. 

Definition. — A new growth of the integument and the mucous membranes, 
composed of fattily infiltrated connective tissue, and characterized by the appearance 
of circumscribed yellow plates, papules, or tubercles, situated most commonly 
upon the eyelids. 

Symptoms and Course. — Xanthoma appears as yellow, yellowish-white, or yel- 
lowish-brown patches, nodules, or larger masses embedded in the skin or mucous 
membrane, and sometimes projecting above the surface. Their consistency is soft, 
and the integument over them feels velvety and normal. They begin as minute 
nodules, increase slowly up to a certain size, and then remain stationary for life ; in 
the rarest instances only do they undergo spontaneous involution. They are some- 
times seen in children, but are commoner in adults, more especially in females of 
dark complexion ; and they are sometimes associated with gout and hepatic dis- 
orders. They are accompanied by no subjective symptoms at all, and are obnoxious 
only for cosmetic reasons, and occasionally because of their interference with the 
use of joints when situated around them. 

Several varieties are to be distinguished. Xanthoma planum is by far the com- 
monest form, and appears as bean- to finger-nail-sized, distinctly limited plaques or 
streaks, which a close inspection reveals to be composed of a multitude of fine yel- 
low nodules, each one with a minute central pinkish point. They are soft and 
usually not elevated. They occur most often upon the eyelids, appearing first at 
the inner canthus, and gradually spreading as confluent patches or separate plates 
over the lid and even onto the cheeks and nose. Patches may also appear upon 
the neck and on the oral mucous membrane. Xanthoma tuberosum may coexist 
with the plane form, and consists of papules or tubercles or roughened plaques of 
varying size, somewhat firmer in consistency than the former variety, and covered 
with an unaltered epidermis. Sometimes the growths form sessile or pedunculated 



270 ILLUSTRATED SKIN DISEAS] S. 

tumors, usually of small size. Their commonest seat is over the flexures of the 
joints and on the hands, feet, and scalp. Xanthoma diabeticorum is a rare variety 
that occurs in connection with diabetes. The papules are numerous, conical, dis- 
crete or confluent, and of the characteristic color with red areoli. The new growth 
has been seen on the buttocks, loins, elbows, face, palms, soles, scalp, and in the 
mucous membrane of the mouth. It is sometimes quite extensive. It differs fn m 
xanthoma of the ordinary variety in its rapid development; and it may disappear as 
quickly, leaving no trace behind. 

Etiology. — The causes of xanthoma are obscure ; some cases are apparently 
hereditary, and others seem to occur in connection with diseases of the liver. In 
xanthoma diabeticorum the skin lesion has been seen to disappear spontaneously 
with the disappearance of the glycosuria, and there seems to be ground for the belief 
that there is a connection between the two symptoms. 

Pathology. — Xanthoma is a connective-tissue new growth of the corium covered 
with a thin epithelium. Its yellow color is due to the fatty infiltration of the new 
elements. 

Diagnosis. — The chamois-yellow patches embedded in the corium, with no 
change in the texture of the skin that is perceptible to the touch, are characteristic. 
The tumors of milium, which occur in the same situation, are tense, hard, and white ; 
they are superficially situated in the epidermis, and their contents are expressible. 

Prognosis. — The tumors cause little trouble. They occasionally require removal 
on account of the disfigurement that they entail, or because they interfere with the 
patient's work. 

Treatment. — The xanthoma tumors or plaques may be removed with the 
curette, excised, or destroyed with the Paquelin cautery or by electrolysis. When 
they are situated upon the eyelids care must be taken to avoid deformity, as ectro- 
pion, etc., from the contraction of the resulting scar. 

SARCOMA. 

Synonym. — Sarcomatosis cutis. 

Definition. — 'Single or multiple, various-sized and -shaped, white or pigmented 
malignant tumors of the skin and subcutis. 

Symptoms and Course. — The affection usually occurs secondarily to sarcoma of 
the internal organs, and belongs to the domain of surgery. It is rare as a primary 
affection of the skin, and is seen in three forms. The commonest is the melanotic 
sarcoma, or melanosarcoma, in which the affection begins as discrete, rounded or 
lobulated, pea- to bean- or egg-sized tumors, of a grayish-brown or bluish-black 
color. There may be a single tumor or several. As they increase in size, adjacent 
tumors may coalesce to form irregular, various-sized, projecting masses, in which 
ulceration not infrequently occurs. Their commonest site is on the backs of the 
hands and feet, on the genitals, or on the face near the orbit. They originate not 




TYPOGRAVURE. 



COPYRIGHT BY F. E. TREAT i CO., N. Y. 



ICHTHYOSIS HYSTRIX. 



PLATE XXIV. 



NEW GROWTHS. 



271 



infrequently from a pigmentary mole or a naevus, from the pigmented tissues, and 
from the general integument in the colored races. 

The non-pigmented sarcoma is rarer, and appears as one or more isolated, hard, 
elastic tumors, usually small in size, and covered with smooth, shining, white or 
sometimes reddened epidermis. As the growths increase in size they may coalesce 
to form nodular plates and masses. The localized form frequently begins in a naevus 
or a warty growth that has been irritated. In the generalized form the numerous 
tumors are smooth and spherical, cutaneous or subcutaneous, growing rapidly and 
coalescing into larger infiltrations which finally undergo ulceration. 

Still rarer is the multiple pigmented form, which differs from the preceding in 
that the tumors are more or less deeply discolored from the hemorrhages that occur 
in their substance. They begin as a few or many pinhead- to pea-sized, brownish- 
red, bluish, or purplish, smooth, shining nodules. These increase in size, multiply, 




Fig. 131. — Sarcoma cutis. 
From photograph by the author. 



and become confluent, forming larger rugose infiltrations. Ulceration is rare, but 
the central portions of the masses not infrequently undergo involution, forming 
cicatricial, darkly pigmented depressions. The isolated tumors may also undergo 
resorption or become gangrenous. Late in the disease sarcomatous nodules appear 
in the mucosae of the respiratory and the gastro-intestinal tract. 

Sarcomatous tumors of the localized form occur most often on the backs of the 
hands and feet and on the face; in the more diffused forms the skin of the trunk and 



'll'l ILLUSTRATED SKIN DISEASES. 

extremities is chiefly involved. Their number varies greatly ; there may be one, or 
only a few, or hundreds of them. Their course also is very uncertain. In some 
cases they take years to spread, apparently remaining stationary or even retrogress- 
ing for long periods of time, and the general health remains good. In most instances, 
however, their progress is rapid, and coalescence and ulceration soon set in. In all 
cases death ultimately occurs from exhaustion, intercurrent disease, or sarcomatous 
involvement of the viscera. Sarcoma occurs not infrequently in youthful individuals, 
and the disease takes from two to six years to reach a fatal termination. 

Etiology. — The cause of sarcoma is unknown to us. Melanotic sarcoma, in at 
least one fourth of all cases, has developed from a wart or a naevus. Certain races, 
notably the Russian and Polish Jews, seem especially prone to the affection. 

Pathology. — Sarcoma is a growth composed of embryonic connective tissue 
with round or spindle-shaped cells. The pigmented forms show hemorrhages, and 
pigment granules in the new cell- mass. 

Diagnosis. — The small, painful, sometimes discolored tumors, beginning on the 
hands and feet, are not especially characteristic. The diagnosis is frequently a 
matter of difficulty, largely on account of the rarity of the affection. Examination 
of an excised piece under the microscope is usually necessary. Sarcoma is most 
likely to be confounded with gumma ; but in this latter the tumors are not so 
numerous, they run a quicker course, and rapidly go on to ulceration. The palmar 
and plantar syphilide, fibroma, and the tumors of lepra, lupus, and mycosis 'fun- 
goides might possibly be confounded with sarcoma; but it is not necessary to re- 
capitulate their characteristics. 

Prognosis. — This is bad in most cases. The disease usually ends fatally, though 
involution and recovery are recorded. 

Treatment. — Prophylaxis consists in the removal of warts and naevi that might 
form the starting-point of sarcoma. Excision is, of course, to be advised in all 
cases in which the number, size, and location of the tumors render it practical; but 
the results have not been good, since return in situ or metastasis finally occurs. 
Good effects have been seen from the long-continued subcutaneous injection of 
arsenic, as recommended by Kobner; and both he and Shattuck have seen a com- 
plete cure effected. Fowler's solution, diluted with 2 or 3 parts of water, must be 
injected every other day or every third day in full doses. It should be tried in 
every case, since it is claimed that it retards the development of the tumors, even if 
it does not cure the disease. 

2. NEW GROWTHS OF MUSCULAR TISSUE. 

MYOMA. 

Dermato- or leiomyomata are extremely rare new growths of the skin, composed, 
as their name indicates, of unstriped muscular fibers, which are arranged in a net- 



NEW GROWTHS. 273 

work bound together by a greater or less amount of connective tissue. There may 
be a single tumor, which may be as large as a hen's egg, and exhibit a slow vermic- 
ular motion; but more frequently there are a number of small, red, hard tumors 
scattered over the body. They are seated in the cutis and covered with a normal 
epithelium ; and they are most often found in places that are abundantly provided 
with smooth muscle, as in the region around the mamilla, on the scrotum, labia 
majora, etc. ; but they may originate anywhere on the body from the arrectores 
pilorum. Sometimes they occur in combination with other tissue, forming fibro- 
myomata, angiomyomata, etc. Their growth is extremely slow, and they hardly give 
rise to any subjective symptoms. Their etiology is unknown, and the diagnosis can 
only be made by the microscopic examination. Arsenic has been recommended in 
their treatment; but enucleation or excision, or removal by electrolysis or the liga- 
ture, is preferable. 



3. NEW GROWTHS OF VASCULAR TISSUE. 

ANGIOMA. 

Synonyms. — Naevus vasculosus, naevus sanguineus, telangiectasis, angioma cav- 
ernosum, tumor cavernosus, port-wine stain, mother's mark, Gefassmal (Ger.), tdche 
de fen (Fr.). 

Definition. — New growths of the skin composed of vascular tissue. 

Symptoms and Course. — Three kinds of vascular new growths of the skin are to 
be distinguished : 

Naevus vasculosus, sanguineus, or flammeus is a vascular anomaly that is visible 
at birth or shortly afterward, and is often combined with some increase of the con- 
nective tissue of the area involved. It usually appears as a smooth, sharply limited 
discoloration ; but it is sometimes rugose and more or less elevated, so as to form 
papular or tubercular or even cauliflower-like elevations. Naevi are most com- 
monly composed of capillaries, and then their color varies from a light to a dark red ; 
arterial naevi are bright red in color, and venous ones dark blue or violet. They 
are found most often upon the head, but they also occur upon other parts of the 
body. They may be single or numerous, small or large, superficial or deep-seated, 
and are almost always compressible. They usually increase slowly after birth until 
they have attained a certain size, and then remain stationary. In some cases, how- 
ever, they undergo spontaneous involution ; adhesion of the walls of the vessels and 
obliteration of their lumen occurs, and a small amount of cicatricial tissue remains to 
mark the place of the vascular tumor. In rare cases thrombosis, followed by gan- 
grene, occurs. 

Telangiectasis is an acquired vascular overgrowth, consisting mainly of an enlarge- 
ment of preexisting vessels, without increase of the connective tissue. The capilla- 



274 



ILLUSTRATED SKIN DISEASES. 



ries and the fine arterial and venous branches are involved, forming a simple stain 
of the skin, or appearing as a plexus of fine dilated vessels often arranged in radiate 
order around a central spot (naevus araneus). Its color varies from a bright red to 

a bluish purple, depending 
upon the preponderance of 
arterial or venous branches 
in the spot. Its size is from 
that of a small pea upward. 
Telangiectases are situated 
most commonly about the 
face ; and, when localized 
about the nasal or buccal ori- 
fices, they may spread on to 
the mucous surfaces. They 
appear most commonly in 
middle life, and increase in 
size and number as the pa- 
tient progresses toward old 
age. They form a part of 
the ordinary symptoma- 
tology of rosacea. 

Angioma cavernosum is 
also a non-congenital form, 
appearing as rounded, often 
fairly large-sized tumors 
which are both compressible and erectile and are frequently pulsating. They are rare 
new growths, and vary in color like the ordinary naevi. 

Etiology. — Our knowledge of the etiology of these growths is very unsatisfac- 
tory. There is no proof that they are in any way connected with antenatal mater- 
nal impressions, the popular belief to the contrary notwithstanding. The telangiec- 
tases are often symptomatic, being the expression of an attempt at a collateral 
circulation when there is obstruction from a tumor or the contraction of new-formed 
connective tissue, etc. Some of these vascular overgrowths occupy the area supplied 
by a cutaneous nerve; but their relationship to the nerve-distribution is unknown. 
Pathologfy. — Naevi consist of dilated and hypertrophied or newly formed arte- 
ries, veins, and capillaries, usually covered with a normal epidermis. More or less 
newly formed connective tissue is present in all cases, though in the telangiectases it 
is not apparent ; and there is often an increased development of the sebaceous glands, 
hair-follicles, arrectores pilorum, and fatty tissue (naevus lipomatodes, angio-ele- 
phantiasis). The cavernous angiomata are composed of true erectile tissue, there 
being a connective-tissue framework with large spaces lined with endothelium, these 




Fig. 132. — Nsevus venosus. 

From photograph by the author. 




COPYRIGHT BY E. B. TREAT & CO., N. Y. 



PHOTOGRAVURE i COLOR CO. , N. 



NAEVUS VASCULOSUS 

PLATE XLIII 









I free commi veen 

the . and ye 

Diagnosis.- The flat re purplish 

ins, the I outoro. • charac- 

teristic. 

Prognosis, 
treatment, . 

i sometimes disappear ■ 
ulceration. In g 
the 

Treatr 

■ 

and telangiectases may 
on a number of layers of 
J29, p. 251), the sur 
tected with plasl 
tion being aV- 
off. Cau ti 
app'h 
days, 

- 

zinc or 
advisal 
Vaccinat 







. 






a needle being e 

Cross-hatch. 

skin in a series of pai 

with the ether spray 

by pressure. 

fixed on a co 

bolic or 

all exten 

'- 



them 
lions of ■ of 

occui 

thai 

1 throug ted 

> ;:en 
- 
aeedles 
■per-cent. car- 
at 

new 

oain an ....- imal 

• that employed f 
:, or several mounted upo> 






NEW GROWTHS. 



275 







_ 








latter forming a free communication instead of the ordinary capillary one between 
the arteries and veins. 

Diagnosis. — This can hardly present any difficulties. The flat reddish or purplish 
stains, the blue and red projecting tumors, and the erectile outgrowths are charac- 
teristic. 

Prognosis. — This depends largely upon the 
treatment, and must be cautiously expressed. 
Nasvi sometimes disappear spontaneously or by 
ulceration. In general the prognosis is better in 
the telangiectases and simple stains than in the 
larger and the erectile tumors. 

Treatment. — This should only be undertaken 
when the vascular new growth is rapidly increas- 
ing, or for cosmetic reasons. The smaller stains 
and telangiectases may be removed by painting 
on a number of layers of the sublimate collodion 
(No. 129, p. 25 1), the surrounding parts being pro- 
tected with plaster or collodion, and the applica- 
tion being allowed to remain in place until it peals 
off. Caustic potash, 3i— iv, to water, 5i, may be 
applied two or three times at intervals of a few 
days. In the very superficial forms painting the 
affected surface with nitric acid or the acid nitrate 
of mercury is sometimes efficacious ; and very min- 
ute naevi may be destroyed by plunging a red-hot needle into them, or by means of 
the Paquelin or the galvanocautery. The injection of solutions of the chloride of 
zinc or of tannin, or of the tincture of the chloride of iron, into these growths is not 
advisable, inflammation, sloughing, and even death having occurred therefrom. 
Vaccination upon the n void growth may be tried in suitable cases, punctures with 
a needle being employed to avoid the hemorrhage that would follow scarification. 
Cross-hatching with the scarificator (Fig. 15, p. 50), cutting through the affected 
skin in a series of parallel and crossed lines, is effective. The part should be frozen 
with the ether spray beforehand, and the hemorrhage, which is free, can be controlled 
by pressure. Multiple puncture is recommended by Sherwell, a bundle of needles 
fixed on a cork or other suitable holder, and dipped into a 50- or 90-per-cent. car- 
bolic or a 25-per-cent. chromic-acid solution, being used. Where the angioma is at 
all extensive, it must, of course, be operated upon in sections. 

Electrolysis, however, is by far the best method of treatment for these new 
growths, being both successful and safe, with no subsequent pain and a minimal 
amount of scarring. The process is exactly similar to that employed for the removal 
of hairs (p. 49). A single needle, or several mounted upon one holder, may 



FlG. 133. — Papillary ncevus. 
From photograph by the author. 



276 ILLUSTRATED SKIN DISEASES. 

be employed. In the flat angiomata the needle should be passed horizontally 
through the skin among the enlarged vessels ; visible ones can be pierced singly, 
and the more projecting tumors should be transfixed through their bases in various 
directions. A current as strong as the patient can comfortably bear should be 
employed, varying from 2 to 10 milliamperes, depending upon the sensitiveness of 
the region operated upon, with the object of destroying the vascular walls and coagu- 
lating the blood within them. 

Warty and pigmented nsevi may be curetted or excised, or removed with the 
Paquelin or treatment of the galvanocautery. The pendulous forms require excision 
or the ligature ; but the larger growths, angio-elephantiases, and the cavernous 
tumors belong to the domain of general surgery. 

LYMPHANGIOMA. 

This rare tumor of the skin is composed of dilated, hypertrophied, and newly 
formed lymphatic vessels, together with a varying amount of new connective tissue. 
It appears in two forms. In the commoner, lymphangioma simplex, there occur small 
aggregations of irregularly grouped, deep-seated, transparent vesicles, with thick walls, 
and with healthy skin between the patches. The tumors are usually multiple, deeply 
seated in the cutis, and pinhead- to pea-sized ; they are colorless or pinkish, or 
somewhat darker and resembling warts. On pricking them a colorless fluid con- 
taining a few lymphatic cells exudes from them. They begin in youth, running a 
very chronic course, and spreading slowly by the formation of new groups of vesicles 
outside the original patches. Lymphangioma cavernosum is even rarer, and is usually 
congenital. Its structure is similar to that of the cavernous angiomata, but it con- 
tains lymph instead of blood. It affects a circumscribed portion of the body, as the 
tongue or lips, causing a diffuse enlargement of the part (macroglossia, macrochilia). 
Of the treatment of these conditions not much need be said; the general health is 
good, and surgical interference is not advisable. Destruction by caustics or excision 
is apt to be followed by the appearance of new lesions at the margins of the patch. 
Electrolysis, as done for hirsuties and naevus, has given good results in Crocker's 
hands. 

4. NEW GROWTHS OF GLANDULAR TISSUE. 

ADENOMA. 

New growths composed of glandular tissue are of rare occurrence in the skin, and 
may develop from the sebaceous or the coil glands ; they may be found wherever 
these structures are present, but have been most often seen on the neck, head, and 
face, more especially upon the sides of the nose and on the forehead. They may 



NEW GROWTHS. 277 

be congenital or acquired, and appear as pinhead- to pea- and even marble-sized, 
rounded or acuminate tumors, firm or soft, and of a normal color, or a yellowish- or 
brownish-red hue. They may remain stationary or undergo fatty or colloid de- 
generation, or ulcerate spontaneously, leaving scars behind. When they grow from 
the sweat-glands the tumors contain a drop of clear encysted fluid. A positive diag- 
nosis, and a differentiation from steatoma, lipoma, and epithelioma, usually require a 
microscopic examination. The prognosis is good, and the treatment consists of their 
removal by surgical measures. 

CARCINOMA. 

Synonyms* — Cancer, epithelioma, epithelial cancer, cancroid, Krebs, EpitJieliom 
(Ger.), epitheliome, cancroide (Fr.). 

Definition. — A malignant new growth of the skin, characterized by the develop- 
ment of heterologous epithelium in the corium and subcutis, appearing as infiltrations 
and ulcerations of the skin, and terminating in death by exhaustion or from infection 
of the internal organs. 

Symptoms and Course. — Carcinoma occurs in the skin, as in other organs, either 
as a primary or a secondary new growth, and usually in individuals over forty years 
of age. General considerations as to its nature and treatment belong to the domain 
of genera' surgery. Certain varieties, however, are peculiar to the skin and mucosae, 
and are of common occurrence there ; and the others will be considered only in so 
far as they are of interest to the dermatologist. 

True carcinoma cutis is always of the scirrhus variety, and is usually a secondary 
affection, spreading either by contiguity or metastasis from cancer of the breast or 
of the alimentary canal. A lenticular and a tuberous form occur. 

Carcinoma lenticulare is the commonest variety of the cutaneous scirrhus, usually 
appearing in the scar or in the skin of the chest after the extirpation of a cancerous 
breast. It begins as multiple, various-sized, very hard, smooth, and glistening nod- 
ules of a dull brownish or reddish color. At first they are deep-seated and dis- 
crete ; but as they increase in size they project above the surface of the skin and 
coalesce into irregular tuberous masses. Not infrequently they form large indurated 
plates which may cover the chest with a stiff, leather-like envelop and impede res- 
piration (cancer en cuirasse). The vascular supply is finally interfered with, and 
ulcerations, often covered with fungous and easily bleeding granulations, occur. The 
lymphatic glands enlarge, and the interference with the lymphatic circulation causes 
marked and characteristic swelling of the neighboring limb. Pain is very great, and 
the process terminates usually in a few months, death occurring from exhaustion or 
from metastasis into the internal organs. 

Carcinoma tuberosum is rarer, and may also be primary, or secondary to cancer 
of other organs. It shows itself as multiple large tubercles, usually distributed ovef 



278 



ILLUSTRATED SKIN DISEASES. 



the body, but most abundant upon the face, head, arms, and chest. The lesions are 
hard, sharply limited, flat or elevated and rounded, and vary from the size of a pea 
to that of an egg. Their color is dull brown, reddish, or violaceous. At first they 

are deep-seated, but they project 
from the surface as they increase 
in size. They remain discrete; 
but breaking down finally occurs, 
and foul and painful fungating 
ulcerations appear. The process 
terminates in death from exhaus- 
tion or from metastasis. 

Epithelioma or cancroid is by 
far the most frequent form of can- 
cer of the skin, forming, according 
to Hyde, ys °f * P er cent, of all 
cases of skin disease. It usually 
begins at one of the points of 
coalescence of the skin and the 
mucous membranes, being seen 
most often upon the face, more 
especially around the eyelids and 
the nose. It is common also upon 
the genitals, especially upon the 
prepuce and the glans penis. It 
occurs also upon the nasal, buccal, 
vaginal, and rectal mucosae, but it 
is much more rarely found in other 
localities. It may originate in nor- 
mal skin or mucous membrane, or 
begin in a wart, a fissure, or an 
excoriation, more especially when 
these lesions have been irritated 
by scratching, the use of caustics, 
etc. A seborrheal patch or a 
senile wart is not infrequently its 
starting-point, and it sometimes 
appears in the scars of syphilitic or lupoid disease. It is preeminently an affection of 
old age, occurring very rarely indeed in the young. Three varieties of epithelioma 
are to be distinguished ; but the pathological process is the same in all of them, though 
they may differ in clinical appearance and mode of growth. The varieties may 
coexist in different portions of the same integument, or develop from one another. 




Fig. 134. Rodent ulcer. 
Case of Dr. L. Weiss. 



NEW GROWTHS. 



279 



1. Superficial discoid or flat epithelioma, rodent ulcer, flache Hautkrebs (Ger.), 
occurs upon the face, prepuce, etc. This is the most benign and least troublesome 
of the epitheliomata, and may exist for years without causing any special inconve- 
nience to the patient. It begins as one or, more rarely, as several neighboring pink- 
ish- or yellowish- white, small, hard papules or disks or flat infiltrations, with a char- 
acteristic dirty waxy hue and a surface that has a glance like that of mother-of-pearl 
and is marked with minute tortuous vessels. It increases very slowly indeed in size, 
and it may be years before breaking down occurs ; but sooner or later an excoriation 
appears upon its surface, covered, perhaps, with a minute crust. This gradually grows 
into a superficial ulceration covered with a scanty viscid secretion. The fully de- 
veloped epitheliomatous ulceration is a more or less circularly shaped, sharply defined 
excavation, with a purplish or reddish base that may be dry and varnished-looking 
or slightly moist, and showing embedded in it peculiar minute waxy bodies, the 
cancroid pearls. The edges of the ulceration are 

prominent, rolled, and somewhat undermined ; and 
both they and the base of the ulcer are of the 
same cartilaginous hardness as the papule from 
which they develop. Very characteristic also is 
the presence of the dilated blood-vessels running 
over the waxy margin. Such an ulceration may 
grow very slowly for many years, spreading over 
the surface, and showing no tendency to spread 
downward. It may cease to enlarge after a time, 
and cicatrization may occur, especially in the center 
of the ulceration ; this is usually partial, but may 
be occasionally complete. More commonly, how- 
ever, the new growth finally invades the deeper 
structures, and develops into the infiltrating or 
papillary form of the disease. Pain is rarely 
marked in this variety of the affection until the 
ulceration is very large ; and the lymphatic glands 
are usually not involved at all, or only very late. 

Since it is almost invariably a disease of old age, the patient frequently dies from 
some other cause. 

2. Deep-seated, tubercular, or infiltrating epithelioma is a rarer affection than 
the superficial form, and runs a much more rapid course. It occurs oftenest upon 
the lips, tongue, and forehead, and may originate in a wart or develop upon normal 
skin. It begins as a number of hard, closely aggregated, pea-sized tubercles, deeply 
seated, and closely united to the subcutaneous connective tissue. The tubercles may 
be flattened or globular, their color is dark reddish or purplish, and their surfaces 
are shiny and marked with dilated and tortuous vessels. As they increase in size 




Fig. 135. — Epithelioma of the penis. 
From photograph by the author. 



280 



ILLUSTRATED SKIN DISEASES. 



they coalesce into a thick infiltrated plaque, which may be elevated or not above 
the surface of the skin, but which shows the characteristic hardness, waxy glance, 
and superficial vascularization. The entire mass may reach the size of a silver dollar 
or a small egg; and isolated nodules, similar in character to the original lesion, 

appear in the skin around the growth. 
In the course of time breaking down 
occurs in the surface or at the periphery 
of the nodules or infiltration, and a char- 
acteristic ulcer results. This isarounded 
or irregular crateriform loss of tissue, 
with an uneven, reddish, often granulat- 
ingand easily bleeding base, and everted, 
raised, hard, and purplish borders. The 
secretion from it is, usually pale yellow, 
viscid, and scanty; but it may be foul 
and purulent if destruction is rapid. 
The hard infiltration of the base and 
margins of the ulcer is marked, and ex- 
tends to the tissues beneath and around 
it. Pain of a sharp, lancinating variety 
is present at all stages, and is very 
marked in the later ones. The deeper 
tissues, fasciae, muscles, cartilage, and 
bone are eventually involved; the lym- 
phatic glands enlarge and sometimes 
break down ; and death occurs from marasmus, exhaustion, or hemorrhage in from 
one to three years. 

3. Papillary epithelioma, malignant papilloma, Blutgezvachs (Ger.), is a rapidly 
fatal form of cutaneous epithelioma. It may occur as an independent growth in 
normal skin, or grow from a mole, a wart, a naevus, or a scar in which enlargement, 
induration, and proliferation of the epithelium occur; or it may develop from the 
superficial or the infiltrating form. It occurs most often upon the glans penis, prepuce, 
scrotum, labia, or the mucous membranes, appearing as a more or less elevated, 
pedunculated or sessile, raspberry-like vegetation of a bright-red color, and so vas- 
cular that it bleeds readily to the touch. Its surface may be dry and covered with 
a yellowish-white epithelium, or macerated and bathed with a foul-smelling, perhaps 
bloody secretion ; and its base is characteristically hard. At first pea-sized and 
slightly elevated, it grows into a projecting, egg-sized or larger, lobulated or spongy 
mass. Fissures, excoriations, and deeper ulcerations occur; the mass finally breaks 
down ; and an ulcer similar to that of the preceding forms results. It is rounded or 
oval in shape, with an irregular base covered with granulations and bathed with a 




Fig. 136. — Papillary epithelioma. 

From photograph by the author. 



NEW GROWTHS. 



281 



serous discharge, or crusted, and with hard eroded or undermined borders of a pur- 
plish-red color. If the infiltration of the cutis is slight, the ulcer will assume the 
form of the superficial epithelioma ; if it is greater in extent, the malignant deeper 
ulceration will result. More or less pain, dull or acute, is usually present during the 
process. In the course of several 
years the fatty tissues, the fasciae, 
the muscles, and the bones become 
involved ; the lymphatic glands en- 
large, harden, coalesce, and break 
down ; and death finally results 
from exhaustion. 

Under the name of Paget's dis- 
ease or eczematoid epitheliomatosis 
is known a very superficial form of 
epithelioma affecting the nipple in 
the female. In the beginning it 
appears as an ordinary but intract- 
able eczema ; when fully developed 
the mammilla and areola are red, 
weeping or crusted, and careful 
examination reveals the presence 
of an induration under and around 
the affected tissues. Moderate 
itching and burning accompany the 
process; one breast only is usually 
affected ; and the cases occur in 
women from forty to sixty years 

of age. After an exceedingly chronic course, lasting for years, it develops finally 
into one of the other forms of the disease. 

Etiology. — In spite of extensive investigations that have been carried on in 
regard to this subject, Ave are still in the dark as to the cause of carcinoma. Certain 
protozoa have been described as the etiological factor by Adamkiewicz and others; 
but their relationship to the disease is doubtful. Heredity seems to be of some 
influence, and cases are on record where several instances have occurred in one family. 
Epitheliomata frequently develop from warts, pigmentary and vascular nsevi, etc. ; 
and in fact all the senile changes of the skin predispose to its occurrence. Irritation, 
either mechanical or chemical, of traumata, warts, ulcerations, etc., seems to excite 
the epithelial overgrowth. This is a factor in the cancer of the lower lip of pipe- 
smokers, the cancer of the scrotum that is seen in workers in paraffin factories and 
in chimney-sweepers, in cancer of the cervix uteri, etc. The malady is very rare 
before middle life, but cases have been reported in children. 




Fig. 137. — Epithelioma of the lip. 

From photograph by the author. 



282 



ILLUSTRATED SKIN DISEASES. 



Pathology. — Carcinoma consists essentially of an excessive proliferation of the 
epithelium, which accumulates in concentric masses contained in connective-tissue 
alveoli. In the skin the growth begins in the rete-cells, and the increasing mass 
extends downward as well as on the surface, penetrating the deeper layers of the 

corium, and causing irritation and in- 
flammatory change. The new cells 
are arranged in compact concentric 
masses or nests ; the central cells 
undergo horny transformation, and 
finally degenerate and break down 
in consequence of insufficiency of the 
blood-supply ; ulceration occurs in 
the center of the mass while cell- 
proliferation is still progressing at the 
margin. Elements of the new growth 
pass into the lymphatic channels and 
cause inflammation and epithelioma- 
tous degeneration of the lymphatic 
glands. 

Diagnosis. — The occurrence of 
the neoplasm in old age, and its ap- 
pearance secondarily to cancer of the 
internal organs, is sufficiently distinc- 
tive for the lenticular and tuberous 
forms of the disease. For epithelioma 
the slowly growing, hard, cartilagi- 
nous, waxy, and transparent tumor 
is fairly characteristic ; and the same 
is true of the ulcerative form, with 
its chronicity and pain, its indurated 
and everted edges showing" the same characters as the original tumor, and its character- 
istic glands. Nevertheless the diagnosis is sometimes a matter of difficulty. Before 
ulceration has occurred the epithelioma maybe confounded with the syphilitic chancre, 
tubercle, or gumma, with an ordinary wart, and with the lesions of lupus and sarcoma. 
None of the syphilitic affections have the ivory hardness, the lancinating pain, the 
peculiar adenopathy, and the very chronic course of cancer; other symptoms of lues, 
past or present, will usually be found; they occur, as a rule, earlier in life, and they 
react to specific treatment. The gumma is never so hard, and goes on fairly rapidly 
to softening and fluctuation. Warts are very liable to be confounded with epithe- 
liomata in the aged, and the diagnosis between them is of special importance, since 
these growths frequently develop into the malignant form of tumor. As soon as a 




Fig. 138. — Fungating epithelioma of the scalp. 
From photograph by the author. 



NEW GROWTHS. 283 

wart becomes painful, irritated, bleeding, or indurated at its base, it should be 
removed. Lupus occurs in youth, rarely beginning after the thirty-fifth year; the 
malady is more diffuse than epithelioma, the lesions are multiple, and the soft, brown- 
ish, translucent nodules are characteristic. Sarcoma is of rapid development and 
takes only a few months to run its course ; it occurs in early life ; there is little ten- 
dency to ulceration, and a great tendency to reappearance in neighboring and dis- 
tant parts. When ulceration of the epithelioma has occurred it must be differentiated 
from the ulcerative syphiloderm and from lupus ; the papillary form must be dis- 
tinguished from condyloma, and Paget's disease from a simple eczema. In the 
ulcerations of luetic disease the marginal induration is not so hard as in cancer, and 
the waxy appearance is absent ; its course is much quicker ; several points are usually 
affected at once ; there is little pain ; and the touchstone of treatment soon settles 
the diagnosis. The lupoid ulceration shows the characteristic nodules outside the 
loss of tissue. Condyloma may resemble a papillomatous epithelioma in its early 
stages very greatly ; but it occurs earlier in life, and the presence of induration and 
ulceration settles the diagnosis in favor of the malignant disease. The induration 
and intractability, together with the extreme chronicity of its course, will distinguish 
Paget's disease from an ordinary eczema. There are always doubtful cases, how- 
ever, in which the excision of a fragment of tissue and its examination under the 
microscope will be necessary. 

Prognosis. — The general prognosis of cancer of the skin is grave, but is dependent 
largely on the variety, location, and stage of the disease. The superficial forms may 
last for many years without interfering with the general health. The true carcino- 
mata, as well as the deeper-seated, nodular, and more destructive varieties of epi- 
thelioma, runs a more rapid course, and may reach a fatal termination in one to two 
years. Of bad prognosis, are excessive pain, a rapidly advancing adenopathy, 
occurrence in advanced age, and location in situations where the growth cannot 
readily be removed. Beginning and superficial cases can be cured by operative and 
other measures ; but recurrences are prone to occur in any form. 

Treatment. — The true cutaneous carcinomata are not amenable to treatment. 
Neither local destruction nor internal remedies have any effect upon the disease, and 
our efforts must be limited to the relief of the pain and the promotion of euthanasia. 

The treatment of the epitheliomata is a purely local one, and consists in the 
removal or the radical destruction of the morbid growth and the neighboring lymphatic 
glands when infected. Excision with the knife, curettement, or destruction with 
caustics may be employed, our choice being determined by the variety, location, and 
extent of the disease. Whichever method is employed must be used on the appa- 
rently healthy tissue outside the limits of the growth ; for the epithelial-cell nests 
and processes extend farther than is visible upon the surface, and any portion that 
is left behind will serve as a nucleus for renewed growth. Upon the mucosae, near 
the orifices of the body, and in general in the very deep-seated and infiltrating forms, 



284 ILLUSTRATED SKIN DISEASES. 

removal by the knife, followed if necessary by a plastic operation to fill up defects 
of tissue, is the most promising and sometimes the only available method. The 
details of such operations, however, belong to the domain of surgery. 

The commoner superficial discoid and papillary forms are better treated by less 
radical measures, cautery, curetting, or caustic applications. Erasion with the sharp 
dermal curette under local anaesthesia (Figs. 18, 19, 20, p. 50) is an excellent measure 
for the removal of the papillary forms of the disease; it is never, however, sufficient 
alone, and is best used as a step preparatory to the application of the cautery or of 
caustic applications. The thermo- or galvanocautery causes little pain and leaves a 
good scar ; it is suitable for smaller growths that are situated on the mucosae or near 
the mouth or eye, situations where caustics cannot be used. Caustic applications 
are to be employed in all cases in which the location of the cancer makes it possible ; 
for they not only cause actual destruction of the cells with which they come in con- 
tact, but they also excite so violent an inflammation in the surrounding tissues that 
the new epithelial structures, less resistant than the healthy tissues, speedily succumb. 
Thus outlying epithelial masses situated in apparently normal tissue, which might 
be left behind were knife or cautery employed, are thoroughly destroyed. Potassa 
fusa is frequently employed. The solid stick, suitably pointed, is bored into the 
growth and its margins in various directions, dilute acetic acid being afterward 
employed to neutralize any excess of caustic action. Healthy tissues may be distin- 
guished by their greater resistance to the point ; the process is not very painful, but 
must usually be repeated several times, an indifferent ointment (No. 26, p. 70, Nos. 
68, 69, p. 135) being employed during the intervals. Pyrogallic acid, I to 4 or 6, in 
ointment or powder (No. 44, p. 100), is a favorite application with Kaposi, Jarisch, 
and others. It is not painful and does not affect the healthy tissues; it must be 
kept in place a week or more, and be followed by the use of an indifferent ointment. 
Trichloracetic acid bored into the mass on a pointed glass rod is efficacious, and 
nitric acid can be used cautiously in the same way. 

No. 132. Hebra's Cosine's Paste. No. 133. Kaposi's Caustic Paste. 

fy Ac. arseniosi 1 part fy Ac. arseniosi ... 2 parts 

Hydrarg. sulphuret. rub. . 3 parts Creosoti . . . . 60 " 

Ungt. aq. rosas . . . 24 " Pulv. opii 1 part 

The best agent, however, for the destruction of the epitheliomata is arsenious acid, 
made into a paste either as Hebra's modification of that of Cosme (No. 132, p. 284), 
together with creosote and opium, as proposed by Kaposi (No. 133, p. 284), or, as I 
think preferable, in the concentrated form suggested by Marsden (No. 7, p. 46). 
Arsenic cannot be used near the eye, since it causes a rather violent inflammation 
of the surrounding tissues; nor upon the margins of the lips, on account of the 
danger of poisoning. But in all other situations, and in all forms save the very deep 



NEW GROWTHS. 



285 



and infiltrating ones, Marsden's paste is the best application and has done me 
excellent service. Its use should be preceded by a curetting to remove papillary 
masses and resistant epithelium. The powered gum arabic and the arsenious acid 
are made into a soft paste with a little water, applied spread upon a cloth, and cov- 
ered with rubber plaster. It should remain in situ for twenty-four hours, or as long 
as the patient can bear the pain. This latter, while constant, is not very severe, and 
is usually well borne ; a little morphia added to the paste will mitigate it. There is 
no danger of absorption, and the arsenic does not affect the healthy tissues, while 
the new carcinomatous cells are thoroughly destroyed. The more extensive growths 
and ulcerations must be treated in sections, not more than 2 or 3 square inches of 
surface being covered at one time. The dead tissue appears as a black necrotic 
mass after the paste is removed, and the part must then be poulticed until the slough 
separates. The simple ulceration that is left behind can be treated with rose-water 
or simple ointment (Nos. 68, 69, p. 135) until it heals. The other arsenical pastes 
are used in the same way. They not infrequently require to be applied twice or 
oftener; but the destruction is radical, and a thin smooth scar is left behind that 
becomes almost invisible in the course of time. Successful removal is shown by the 
rapid and complete cicatrization of the ulceration left after the slough has separated. 
If this does not occur, or if the characteristic cancerous nodules appear in the scar, 
the treatment must be repeated. 



CLASS VL 
ATROPHIES. 



UNDER this heading are classified those changes in the skin that consist essen- 
tially of a diminution in the size or number of the cells of one or more or all the 
tissues that compose that organ. Degeneration not infrequently accompanies the 
process. The whole cutis and subcutis may be affected, as in the various forms of 
circumscribed and partial atrophy, xeroderma, and scleroderma ; or the pigment 
only is involved, as in albinismus, vitiligo, and canities ; or the atrophy may affect the 
hair, as in the various forms of alopecia, or the nails, as in onychatrophia. Certain 
congenital deficiencies of parts of the skin, though not strictly pathological atrophies, 
can be most conveniently considered here. 

U ATROPHY OF THE CUTIS AND SUBCUTIS. 

General atrophy of the skin and subcutaneous tissue may be localized and par- 
tial, or generalized and spread over the whole body. They are rare as idiopathic 
conditions, more commonly occurring together with or following other pathological 
or physiological changes. We shall consider atrophia cutis propria and scleroderma. 

ATROPHIA CUTIS. 

Synonyms. — Atrophoderma, maculae et striae atrophica?, atrophia senilis, xero- 
derma, glossy skin, atrophia neuriticum, atrophy of the skin. 

Definition. — A diminution in quantity of the histological elements of the skin, 
often accompanied by degeneration. 

Symptoms and Course. — Atrophy of the skin may be general or localized, idio- 
pathic or symptomatic. Its various forms differ sufficiently to require separate 
consideration. 

General idiopathic atrophy of the skin is rare as a congenital condition, and is 

286 



ATROPHIES. 



287 



known as xeroderma or parchment-skin, though that name is also employed to 
designate the milder varieties of ichthyosis. In this condition the integument of 
the feet and legs and hands and arms is most markedly affected. The skin is 
thinned, tense, and wanting in pigment; the epidermis is thin and shining; and the 
parts most affected are very sensitive. Idiopathic atrophy of the skin is a not 
uncommon acquired condition in old age. Atrophia senilis is really a physiological 
process, the general integument partaking in the diminution in size that occurs in 
all the tissues in old age. The subcutaneous fat gradually disappears ; the skin 
becomes lessened in thickness, lax, wrinkled, and hangs in thin folds. All the ele- 
ments of the integument save the 
pigment are atrophied; the de- 
crease in the secretion of sweat and 
sebum causes a slight but persistent 
desquamation (pityriasis tabescen- 
tium) ; and the color of the integu- 
ment gradually gets darker, either 
diffusely or in spots. Verrucae seniles 
(senile warts), dirty yellow-brown 
accumulations of sebaceous scales, 
frequently appear, and are very prone 
to undergo carcinomatous degenera- 
tion. The condition is only patho- 
logical when, as is frequently the 
case, it is accompanied by violent 
itching. 

Circumscribed atrophies of the 
skin are of common occurrence, and 
may be idiopathic or symptomatic. 
In atrophia maculosa et striata, macu- 
lae et striae atrophicae, or vergetures 
(Fr.), they occur as stripes or spots 
that at first are red, but in the course of time become purplish, grayish, or silvery 
white, smooth, scar-like depressions. In its commonest form the affection appears 
as a number of parallel stripes 1—2 mm. wide and 1 to several inches long. The 
streaks are isolated, rounded or oval, and pinhead to finger-nail in size. They may 
appear anywhere on the body, but are most commonly seen upon the neck, thighs, 
buttocks, and abdomen. They occur in both sexes, grow to their full size very 
slowly, and, once formed, are permanent. As they cause no subjective symptoms 
at all, their presence is frequently discovered only by accident. 

Localized atrophy of the skin occurs after injury to the nerve supplying the part 
affected. Atrophoderma neuriticum, glossy skin, GlanzJiaut (Ger.), gives us a 




Fig. 139. — Stride atrophicae. 
Case of Dr. A. H. Ohmann-Dumesnil. 



288 ILLUSTRATED SKIN DISEASES. 

thinned, smooth, glossy, and apparently varnished skin, of a pinkish or reddish color. 
The natural lines are obliterated, the hair is lost, and the nails become incurved. 
Vesiculation, ulceration, and gangrene sometimes take place ; and the patients suffer 
from paroxysmal neuralgic pains. The fingers are the parts usually affected. 

Under the name of cutis laxa is known a condition usually hereditary, in which 
the normal extensibility of the skin is greatly increased, and its usually firm attach- 
ment to the deeper tissues is diminished, so that it can be drawn out in folds like a 
sheet of rubber tissue. The condition causes no inconvenience to its bearers, some 
of whom are put on exhibition as rubber- or elastic-skinned men. 

Etiology. — Some forms of cutaneous atrophy are of unknown origin, while others 
are due to obvious mechanical causes. Concerning the cause of the more general 
and congenital cases and of cutis laxa we are in ignorance. Partial atrophy is 
usually due to laceration of the subcutaneous tissues, either from external violence, 
blows, the pressure of corns, favus crusts, etc., or from internal distention, as occurs 
in anasarca, ascites, abdominal tumors, pregnancy, and excessive development of fat. 
It also follows lepra and syphilis. Glossy skin occurs in parts where the circulation 
is bad, and that have been exposed to cold ; and also in gouty, rheumatic, and 
other general conditions. Some cases are distinctly due to nerve injuries, a neuritis, 
perhaps accompanied by muscular atrophy, being the cause of the trophic changes 
in the skin. 

Pathology. — In the various forms of atrophy of the skin the epidermis and the 
mucous layer are thinned, the papillae are flattened out, and the fatty tissue and 
vessels are much diminished in quantity. There is often a marked change in the 
connective tissue of the corium and subcutis. The bundles are much smaller than 
normal, are arranged in parallel rows instead of being interlaced, and fat-cells are 
not present in their meshes. In some cases there is fatty, amyloid, or colloid 
degeneration of the elements of the skin. In an advanced case of cutis laxa 
Ohmann-Dumesnil found myxomatous degeneration of the cutaneous tissues to be 
present. 

Diagnosis and Prognosis. — The diagnosis of these various conditions presents no 
difficulties. The prognosis is generally bad ; most of the changes are permanent, 
and we are limited in treatment to the relief of the symptoms that they may cause. 
The neuritic form tends to get well when its cause is removed. 

No. J34. Cocaine Ointment. 

$ Cocain. hydrochlor. . . i part 

Petrolati . . . .20 parts 

Treatment. — This can only be symptomatic, and consists of the use of emollient 
applications (No. 26, p. 70, No. 29, p. 74, No. 54, p. 113, Nos. 65, 66, 67, p. 135) 
to relieve the dryness, and antipruritics (Nos. 11, 12, p. 56) to mitigate the itching 



ATROPHIES. 289 

of the senile forms of the malady. Glossy skin tends to get well if protected from 
cold and other external irritants. Cold or very hot water may be used to relieve 
the pain; as also a cocaine ointment, 5 to 10 per cent. (No. 134, p. 288). 

SCLERODERMA. 

Synonyms. — Sclerema adultorum, dermatosclerosis, morphoea, sclerodermic (Fr.), 
Hautsclerem (Ger.). 

Definition. — 'A chronic disease of the skin, characterized by circumscribed or 
diffuse, waxy or pigmented induration of the skin, with subsequent rigidity, fixation, 
and atrophy of that organ, and ending in resolution or permanent cicatricial fixation, 
and sometimes in death from marasmus. 

Symptoms and Course. — This rare disease begins insidiously, without any local 
or general symptoms, or accompanied only by slight malaise and rheumatoid pains, 
and itching and formication in the parts about to be affected. It begins with the 
stadium elevatum, in which larger or smaller areas of the skin become cedematous, 
thickened, hardened, and elevated. The integument of the affected parts is moder- 
ately tense, immovable, of a rosy or ivory-like and waxy appearance, and very 
shiny ; the parts look as if they were frozen, and are sometimes covered with a slight 
desquamation. The spots spread slowly by peripheral extension to a certain size; 
and the malady may retrogress spontaneously at this period of the disease, but it 
usually goes on to the second stage, the stadium atrophicum. Here the affected 
skin is shrunken, thinned, scar-like, depressed, and shiny. It is firmly adherent to 
the subjacent tissues, which are also involved in the process, and its color may be 
normal, or white and ivory-like, or pigmented, or even bronzed. Two distinct forms 
are to be mentioned, in accordance with whether the process remains a localized 
one or spreads over large areas of skin or the whole body. 

In scleroderma circumscriptum or morphoea one or more rounded or oval areas 
or stripes of varying size appear, which, after passing through the hypertrophic 
stage above mentioned, develop into flattened or depressed lesions of a dead-white, 
ivory, or pinkish color, usually bordered by a violaceous or pinkish zone of dilated 
vessels. The patches are dry and smooth ; the natural lines of the skin are oblit- 
erated ; the hairs disappear; and the surfaces may be corrugated from contraction. 
They may long remain in this condition, and then they may slowly fade away or 
gradually spread by the appearance of new lesions at the margins and their slow 
coalescence with the original patch. The affected areas may appear anywhere, but 
are most often seen upon the limbs, head, and neck ; they usually persist for many 
years ; atrophy of the deeper tissues and adhesion to the skin, with subsequent 
contractures and deformity, sometimes occur ; but there are no symptoms, either 
special or general, save slight itching and an absence of sweat. Sensibility is usu- 
ally undisturbed. 



290 ILLUSTRATED SKIN DISEASES. 

Scleroderma universalis is the variety of the disease in which larger areas or the 
entire skin is affected. After perhaps the indefinite prodromal symptoms above 
mentioned the affected skin becomes obscurely oedematous, elevated, and slightly 
reddened; and it gradually becomes more and more indurated until it assumes the 
consistency of hard leather. The integument looks waxy, or is of a dirty yellow 
color ; the margins of the infiltration fade gradually into the normal skin, and the 
affected area is firmly bound down to the subjacent parts. Finally the skin becomes 
thinned and hide-bound, and apparently too small for its contents. The muscles 
become affected with a true interstitial myositis, followed by atrophy, and even the 
fasciae and bones become involved; so also do the mucosae, more especially of the 
mouth and throat. Sensibility is little affected, though there may be a troublesome 
pruritus. The secretion of the sweat and sebum is diminished or absent. The firm 
tension of the skin of the affected parts renders them very liable to injury from 
slight causes, and ulcerative processes are readily set up. 

The appearance of a well-developed case varies with the part affected. The face 
is fixed — gorgonized, as it were ; the features are immovable and stony ; the mouth 
can be opened with difficulty; the lips are shortened; the gums are shrunk; the 
nostrils are compressed. The strained, pallid skin and the expressionless features 
give the face a ghastly, corpse-like appearance. If the limbs are affected, the fin- 
gers are semiflexed and rigid (sclerodactylie), the nails are hypertrophied (onycho- 
gryphosis), and all the joints covered by the sclerosed skin are fixed and rigid. 
Walking may become impossible. On the chest wall the breasts are flattened and 
almost obliterated, and respiration is interfered with. 

The malady often remains stationary for years. In the early stages recovery 
may take place, but in the later ones, when the lesions have become atrophic and 
the parts fixed, a return to the normal is impossible. The patients die of marasmus 
or of intercurrent disease. 

Etiology. — We know nothing certain in this regard. The malady occurs much 
oftener in females than in males, and most frequently in youth or early adult life. 
Attacks of rheumatism and of erysipelas, privation, exposure, and mental worry 
seem to be etiological factors in some cases, but often there is no such history. It 
is probably connected in some way with a lesion of the central nervous system. 

Pathology. — This is equally obscure. There is a small-celled new growth 
around the vessels, with subsequent thickening and atrophy of these structures and 
obstruction to the flow of the blood and the lymph. The epidermis is thinned and 
pigmented ; the fat is atrophied, and the ordinary connective tissue and elastic fibers 
are enormously increased. The contraction of this new tissue finally binds all the 
structures of the skin together into a sclerotic mass. 

Diagnosis. — This is usually not difficult in view of the solid, white, indurated, 
parchment-like skin. Vitiligo is milky-white in color and shows no structural 
change. Sclerema neonatorum occurs immediately after birth, while ordinary 



ATROPHIES. 291 

scleroderma is rare in very young children. Keloid is distinctly limited in area, 
and hypertrophic. The trophic changes of syringomyelia and lepra are accompanied 
by analgesia, and in the former there is the marked change in the temperature-sense. 
Cancer en cnirasse may greatly resemble a scleroderma, but it is usually secondary 
to cancer of the breast ; the characteristic nodules are deep-seated, firm, and pig- 
mented ; there is unilateral oedema and lymphangitis, as well as an indurated mar- 
gin, great tendency to ulceration, and a rapidly fatal course. 

Prognosis is doubtful. Some cases, more especially in the earlier stages, and 
in the circumscribed forms known as morphcea, recover. Other cases last for years 
without the general health becoming affected. After atrophy has set in restitution 
to the normal is impossible ; and if recovery occurs at all, it is with thinned and 
adherent skin, deformity, and fixation of the joints. Perhaps 20 per cent, of all 
cases terminate fatally. 

Treatment. — Recovery occurs spontaneously in some cases, which accounts for 
some of the cures reported from the use of the iodide of potash, mercury, arsenic, 
etc. Removal to a dry and equable climate, together with tonics, iron, strychnine, 
and cod-liver oil, and general hygienic measures, are undoubtedly of importance. 
Massage of the affected parts is especially useful, and should be combined with daily 
hot-water or sulphur or vapor baths. Galvanism has done good in some cases. 
The thorough inunction of olive-oil into the affected skin two or three times daily 
is an excellent measure, either alone or combined with massage or electricity. 

SCLEREMA NEONATORUM. 

Synonyms. — Scleroderma neonatorum, sclerema of the new-born, algidite pro- 
gressive (Fr.). 

Definition. — A progressive, hard oedema, with discoloration and coldness of the 
skin, appearing at birth or shortly thereafter, and usually terminating fatally within 
a few days. 

Symptoms and Course. — Sclerema of the new-born is seen chiefly in foundling 
asylums among the prematurely born or weakly children of the poorer classes. It 
appears at birth or a few days after it, beginning as a hard cedema of the skin of 
the lower extremities, which gradually spreads over the rest of the body. In 
exceptional cases it begins on the head or face, and in other exceptional cases it 
remains localized in certain areas and does not spread over the entire body. The 
skin at first is swollen, yellowish-white or waxy-looking, shining, hard, and cold. 
In a short time the cedema goes down, but the skin remains hard and mummified, 
and is of a dusky reddish or livid color. It is firmly attached to the deeper tissues, 
and cannot be wrinkled or pinched up into folds. As the process spreads to the 
subcutis and the muscles the joints become immovable from the hardening of the 
surrounding tissues; the face is fixed and motionless; and the entire body is rigid 



292 ILLUSTRATED SKIN DISEASES. 

and cold as if in a condition of rigor mortis. The pulse falls to 60; the respirations 
are shallow from the stiffening of the chest walls, and are 14 or less to the minute, 
and the temperature is several degrees below normal. The infant's vitality may be 
so depressed that even the cry is absent. The fixation of the facial muscles is rarely 
complete, but their stiffness interferes with or may entirely prevent suckling. Icte- 
rus is commonly present ; diarrhea and vomiting may set in, and the cases in which 
the entire integument is affected usually die before the ninth day. Partial cases 
sometimes recover. 

Etiology. — The immediate cause of the sclerema is a retardation of the circula- 
tion in the cutaneous capillaries, possibly due to disease of the vessel walls. Con- 
genital syphilis, intra-uterine, pulmonary, and intestinal disease, exposure to cold, etc., 
are supposed to be among the factors that cause its appearance. 

Pathology. — The epidermis of the scleremic skin is thickened, and the connective 
tissue is increased, while the fatty tissue is mostly or entirely gone. The lumen of 
the vessels is much diminished. Some observers have found a partial crystallization 
of the fat that remains in the connective-tissue cells. 

Diagnosis. — The indurated oedema, the color, the coldness, together with the age 
of the patient, are characteristic. The only malady with which it might be con- 
founded is scleroderma ; but this latter is very rare indeed in infants and has a 
much more chronic course. 

Prognosis. — This is bad, since most cases die in a few days. Signs of bad omen 
are rapidly increasing weakness, quick spreading of the induration, a greatly sub- 
normal temperature, the occurrence of hemorrhage, icterus, etc. A few of the 
incomplete cases recover. 

Treatment. — We may endeavor to compensate for the fall in temperature by 
keeping the child in an incubator, enveloping it in cotton-wool, or by the frequent 
use of hot baths. Nutrition must be kept up as well as possible by artificial feeding 
if the child cannot nurse, and both food and stimulants must be introduced by means 
of a tube passed through the nose if the rigidity of the mouth and throat is such 
that they cannot be administered in the ordinary way. Systematic massage, and 
rubbing the body with warm oil or camphorated alcohol, are useful to stimulate the 
circulation. Galvanism of the sympathetic nerve has been recommended. 

2. ATROPHY OF THE PIGMENT. 

Absence of the pigment of the skin occurs as a congenital or an acquired condi- 
tion, and may be partial or general. The form known as albinismus is not an 
atrophy ; it is a congenital deformity of the skin and its appendages, which can 
most appropriately be considered here. Acquired atrophy of the pigment is known 
as vitiligo, and when the hair alone is affected, as canities. Loss of pigment, together 
with atrophy of other elements of the skin, occurs in morphcea and in maculae and 






TYPOGRAVuRE. 



9. TREAT A CO., N. Y. 



LEUCODERMA. 



PLATE XLIX. 



ATROPHIES. 293 

striae atrophica?, which have already been considered. Some of these affections are 
much commoner in the colored than in the white race. 

ALBINISMUS. 

Synonyms. — Congenital achroma, congenital leucoderma, albinism. 

Definition. — A congenital absence of pigment in the skin and its appendages. 

Symptoms and Course. — Albinism is an anomaly that occurs in the lower animals 
as well as in man, and may be general or partial. In albinismus universalis the pig- 
ment is congenitally absent from all the normally pigmented surfaces of the body, 
the skin, the hair, and the iris, choroid, and retina. The integument is milky white 
or pinkish in color; the hair, which is usually very fine and silky, is white or yellow- 
ish white. The eyes look red, from the absence of pigment in the iris, which is of 
a pale-bluish or pinkish hue ; there is photophobia, the pupils are continually in 
motion, and nystagmus is often present. Individuals so affected are known as albinos 
or kakerlaken, and are usually deficient in stature and in mental and physical vigor, 
though their general health is not necessarily bad. They are found in all races. 

Albinismus partialis is a circumscribed congenital absence of pigment, appearing 
as single or multiple, larger or smaller spots, streaks, or areas of a white or pinkish- 
white color. The skin otherwise is perfectly normal. The discoloration is some- 
times symmetrical, and occasionally follows the track of certain nerves. The hair 
over these areas is colorless; but congenital absence of pigment in hair situated on 
normally colored skin also occurs, being known as canities or poliosis circumscripta. 
The affection is much commoner in the negro than in the white race. The spots 
usually remain stationary, but sometimes they spread ; more rarely the pigment is 
redeposited spontaneously in the affected area. 

Etiology. — The cause of the deformity is entirely unknown. It is sometimes 
hereditary, occurring in several members of a family in one or several generations. 
Many cases occur, however, as isolated examples. 

Pathology. — The absence of pigment is the only change in the skin and the 
other tissues. 

Diagnosis and Prognosis. — The entire absence of any symptom, either subjective 
or objective, other than the want of pigment, is sufficiently characteristic. The 
prognosis as to cure is bad ; we know of no measures that will cause the redeposi- 
tion of the pigment. 

Treatment. — This is practically useless. Chrysarobin and salt baths have been 
recommended, but have given no results. 

VITILIGO. 

Synonyms. — Leucoderma, leucoderma acquisita, acquired achroma. 

Definition. — Vitiligo appears as one or more sharply limited, rounded or irregu- 



294 



ILLUSTRATED SKIX DISLA.sK>. 



lar, smooth white spots, increasing in size by peripheral extension, and surrounded 
by a zone of abnormally pigmented skin. 

Symptoms and Course. — Vitiligo is rare in this country, but is commoner in the 
tropics and among the dark races. It usually begins during adolescence or early adult 

life, appearing as one or more 
circular, pigmentless spots, with 
smooth, level, and unaltered sur- 
faces, and whitish or milky in 
color. They are invariably sur- 
rounded by a well-defined, 
darkly pigmented border. The 
size of the spots varies from 
that of a small coin to that of 
the palm of the hand; they in- 
crease by peripheral extension ; 
new ones may appear from time 
to time, and by the coalescence 
of adjacent spots larger irregu- 
lar leucodermic areas, bordered 
by curved lines, are formed. 
Their number is from one to a 
dozen or more, but they are 
usually not numerous, and they 
areoftensymmetrically arranged 
upon the body. The hairs on 
the affected areas are usually 
white (poliosis). The spots ap- 
pear anywhere, but are most commonly seen upon the trunk and the backs of the 
hands. Their course is very chronic ; they extend slowly for years, and then may 
remain stationary ; sometimes they increase until the greater part of the integument 
is involved. They look worse in summer, when the normal skin is most deeply 
pigmented. Beyond the change in color there is no disturbance or alteration in the 
appearance or in the functions of the skin. Symptomatic vitiligo occurs in the 
course of lepra and syphilis. 

Etiology. — Vitiligo is probably trophoneurotic in origin, but its exact cause is 
unknown. Some cases occur after the acute febrile diseases, and others with vari- 
ous affections of the nervous system. 

Pathology. — There is atrophy of the pigment in the whitened spot, together 
with an increase of the same element at its margins. It appears as if the pigment 
were gradually pushed outward as the process advances, so that it accumulates in 
the healthy tissue just outside the affected area. 




Fig. 140. — Leucoderma. 
After Van Haren-Noman. 



ATROPHIES. 



295 



Diagnosis. — 'The whitened spots surrounded by a dark border must be distin- 
guished from the discolorations of chloasma, chromophytosis, morphoea, and leprosy. 
In chloasma the color is yellow or brownish, and there is no accumulation of pig- 
ment at the margins. In chromophytosis the spots are yellowish or reddish brown ; 
the skin around them is normal in color; there is desquamation, and the microscope 
reveals the presence of the characteristic parasite in the scales. In morphcea the 
atrophy is characteristic; as is the anaesthesia, and possibly the presence of 
tubercular deposits elsewhere in the skin, in lepra 
nervorum. 

Prognosis. — Leucodermic spots usually increase 
slowly in area until a considerable extent of the skin 
is involved, and then remain stationary. In excep- 
tional cases the normal pigmentation of the skin 
gradually returns. 

Treatment. — This can consist only of care of the 
general health, the use of tonics, roberants, etc. 
There is little to be hoped for from the local treat- 
ment, though penciling with cantharidal solutions 
or collodion and the use of galvanism have been 
recommended. 

CANITIES. 

Synonyms. — Poliosis, blanching of the hair. 

Definition. — Whitening of the hairs from the 
atrophy of their pigment. 

Symptoms and Course. — Atrophy of the pigment 
of the hair causes it to change from its normal color 
to a grayish or a silvery white. It may be a con- 
genital or an acquired condition. All the hair may 

be affected, or only part of it, and in the latter case the affected hairs may appear 
in scattered tufts or cover a definite area of surface, or they may be distributed 
more or less abundantly among the normally pigmented structures. 

Congenital complete canities is always present in albinismus, where the hairs 
share with the other tissues of the skin in the general absence of pigment. Under 
other conditions it is usually partial, the uncolored hairs being seated on pigmented 
or on non-pigmented skin. 

Acquired canities occurs as a physiological change in old age, either because the 
papillae of the hair no longer produce pigment, or the epithelial cells of the shaft can 
no longer take it up ; but it sometimes appears comparatively early in life, being 
apparently due to an hereditary predisposition. It begins in the scalp around the 
temples, and in the beard, and later extends to the vertex. As a pathological con- 




Fig. 141. — Leucoderma. 
After Joseph. 



296 ILLUSTRATED SKIN DISEASES. 

dition it may occur at any age. Like the congenital form, it may be complete or 
partial. Complete acquired canities is almost always a permanent condition, yet 
Wilson records a case in which the hair was gray in the winter and colored in the 
summer. As a partial affection it is seen in vitiligo, where patches of uncolored hair 
occur upon the whitened areas of skin, in the first hairs that grow upon areas 
affected with alopecia areata, and as a simple white tuft or tufts of hair in the midst 
of normally colored appendages. 

Acquired canities is often an hereditary affection, occurring in families and appear- 
ing either as a general blanching or as grayish or white tufts or patches. It usually 
comes on slowly, but, though the fact has been denied by Hebra, Kaposi, Joseph, 
and others, authentic cases are recorded in which it has appeared with great rapidity. 
Thus in Landois's case of a patient suffering from delirium tremens, the hair of 
the beard and head turned gray overnight ; and Raymond and Vulpian record an 
instance in which the hair turned white in the course of two days in a patient 
suffering from a severe neuralgia following mental strain. Intense mental depres- 
sion, psychic influences, neuralgias, wasting diseases, the fevers, etc., may cause 
grayness and whitening of the hair in a comparatively short space of time. 

Ringed hair, pili annulati, is a very rare condition, in which the hair is marked 
with alternate white and colored bands of varying size. Occasionally the whitening 
affects only a portion, either distal or proximal, of the affected hairs, as in the cases 
reported by Falkenstein and others. 

Etiology. — Congenital canities is a deformity rather than a disease. The dimi- 
nution in the activity of pigment formation in the papillae that is normal in old age 
occurs comparatively early in life in some families. It also occurs during the course 
of severe neuralgias in the hair of the affected area, after the specific fevers, more 
especially after scarlet and typhoid, following prolonged nervous strain, mental or 
bodily in origin, after nervous shocks or prolonged exposure to the emotions of grief 
or fear, etc. 

Pathology. — The color of the hair depends on the quantity and distribution of 
the pigment in its shaft. When the peripheral layer of the shaft contains air and 
not pigment, though the central part may be normally colored, the hair is white. 
There is usually an actual diminution of the amount of pigment. Cases of canities 
of sudden occurrence seem to be due to the appearance of air-bubbles in the shaft 
of the hair. Alternate colors are apparently caused by. the occurrence of successive 
periods of activity and rest in the pigment-producing functions of the follicle. 

Prognosis. — This is in general bad, though in exceptional cases the affected hair 
does regain its color. The canities after alopecia areata is usually temporary, and 
the same is sometimes the case with that following the fevers and general con- 
ditions of depressed vitality. 

Treatment. — A radical treatment of canities is an impossibility, since we possess 
no means of stimulating the pigment supply of the papillae. In the premature forms 
and the partial ones the use of general tonics, with arsenic and local stimulation, may 



ATROPHIES. 297 

be of some benefit. Pilocarpine nitrate, given hypodermically in quantities of n> 
grain, or the tincture of jaborandi in io-drop doses, may be employed, as also may 
the faradic brush. 

In almost all cases, however, these means fail us, and our only resource is to use 
dyes to stain the uncolored hair. The objections to their employment are that they 
discolor the scalp, render the hair dry and dead-looking, and require to be frequently 
applied to the part of the hair next to the skin on account of the rapid growth of the 
pilous structures. The fatty oils give a darker color to the hair, and may be regu- 
larly employed as a dressing; the most useful of these are the oils of mace, walnut, 
and cassia. As true dyes the nitrate of silver, mercury, and pyrogallol are most 
frequently used. Paschkis recommends the following procedure : The hair is cleansed 
with soap and water, rinsed out with warm water, and dried. Then the pyrogallol 
solution (No. 135, p. 297) is brushed on the hair, from the root to the end, by means 
of a soft tooth-brush. This is allowed to dry, and then the silver solution (No. 136, 
p. 297) is applied in the same way. The stains of the skin that are very liable to 
occur accidentally may be removed with a 33-per-cent. iodide-of-potash solution. 
Anderson prefers the use of the bichloride of mercury, followed by a hyposulphite- 
of-sodium solution (Nos. 137, 138, p. 297). The nitrate of silver alone is, however, 
most frequently used (Nos. 139, 140, p. 297), exposure to the sunlight changing the 
hair to brown or black, in accordance with the amount and strength of the solution 
employed. Discolorations of the skin may be removed by washing the parts with a 
solution of the cyanide of potassium, or, more safely, with one of chloride of sodium. 
For the brown shades the pyrogallol dye (No. 141, p. 297) may be used. Whichever 
method is employed, the dyeing must be repeated every two or three weeks. 

No. 135. Paschkis 's Hair-dye No. 1. No. 136, Paschkis 's Hair-dye No. 2. 

R Pyrogallol 1 part ft Argent, nitrat. 1 part 

Aq. dest. . . . . 50 parts Aq. dest. . . . .80 parts 

Aq. amnion, q. s. ad. solut. enasc. sedim. 

No. 137. Anderson'' s Hair-dye No. 1. No. J38. Anderson's Hair-dye No. 2. 



ft 


Hydrarg. bichloridi 


1 part 


R Sod. hyposulphitis 


. 


1 part 




Aq. dest. 




250 parts 


Aquae 


• 


. 8 parts 




No. J39. Kaposi's 


Dy 


? Formula No. 1 . 


No. 140. Kaposi's Dye 


Formula No. 2. 


ft 


Argent, nitrat. 


. 


1 part 


R Argent, nitrat. 


. 


5 parts 




Amnion, carb. 


. 


150 parts 


Plumbi acet. 


. 


1 part 




Ungt. simpl. 




• • 30 " 

No. 141. Pyro t 

R Pyrogallol 
Aq. colognien. 
Aq. rosae 


Aq. colognien. 
Aq. rosae 

<*allol Hair-dye. 

1 part 
... .2 parts 

. 40 




1 " 

100 parts 



298 ILLUSTRATED SKIN DISEASES. 

Change of color of the hair other than whitening is an extremely rare condition ; 
Alibert and Beigel have reported such cases following severe fevers. Discolora- 
tions from the effect of external agents are more common. The excessive use of alkalis 
and alkaline soaps tends to turn the hair red ; oxygen and compounds containing it in 
readily separable (as peroxide of hydrogen) form lighten its hue ; the fatty oils, as those 
of mace, walnut, and chrysarobin, darken it. Various occupations give rise to accidental 
discolorations of the hair; thus that of workers in cobalt-mines and indigo factories 
is liable to be stained blue, that of copper-smelters green, while those employed in 
crude aniline works frequently have their hair stained a dark reddish brown. 



3. ATROPHY OF THE HAIR. 

Atrophy of the hairs occurs as a quantitative change, as in the various forms of 
alopecia and in alopecia areata ; and as a qualitative one, as in several rarer and less 
important conditions, as atrophia pilorum propria, fragilitas, monilethrix, trichor- 
rhexis nodosa, etc. It may be symptomatic, as in the atrophy that occurs with or 
after certain constitutional diseases, as syphilis, diabetes, phthisis, the fevers, etc., or 
it may occur idiopathically, unassociated with any disorder of the general system. 



ALOPECIA. 

Synonyms. — Calvities, defluvium capillorum, baldness, Kahlheit (Ger.). 

Definition. — A diminution in the quantity of the hair. 

Symptoms and Course. — Alopecia is really the name for the symptom of bald- 
ness which appears in the course of various diseases ; but it is used as a generic term 
for baldness from any cause, and is best considered as an entity. It is customary 
to distinguish several varieties, in accordance with the causation, time of appearance, 
etc., of the atrophy. 

I. Alopecia congenita s. adnata. Most infants have plenty of hair at birth; but 
in certain cases it is deficient in quantity, and in rare instances it is entirely wanting. 
The alopecia is usually partial, both in degree and in extent, the hair being simply 
thinner than normal over certain areas. But cases are on record in which the alo- 
pecia was complete over part or even over the whole of the body. Schultz has re- 
ported the case of a man thirty- five years old who never had any hair upon his body, 
save about ten short ones grouped around the corners of his mouth. Sometimes 
the hair grows in later in life ; Luce's case had no hair until its sixth year. The de- 
formity — for it is this rather than a disease — seems to be hereditary and run in 
families, and even a hairless race has been reported by Hill as existing in Australia. 
Marked cases show other defects of the skin, general atrophy, or diminution or ab- 
sence of the sudoriparous or sebaceous secretion, as well as defects of the teeth. 



■ m 



n 



HI 











ALOPECIA AREATA. 



ALOPECIA NEUROTICA. 




TYPOGRAVURE. 




ALOPECIA PITYRODES. 



ALOPECIA TOTALIS. 



PLATE XL.IV. 



ATROPHIES. 299 

2. Alopecia senilis, senile calvities. This is the permanent loss of hair that 
occurs in old age ; it is to a certain extent a physiological process, though it occurs 
most markedly in cases affected with seborrhea sicca. The hair turns gray, be- 
comes dry and lusterless, falls out, and is not replaced. There is often a lanugo 
growth of hair before the definite defluvium sets in. The skin of the affected 
area is at first normal ; but later it becomes atrophic, thinned, shining, and tense. 
The affection is always symmetrical in its spread, beginning at the vertex and 
spreading backward and forward ; the hairs remain longest on the lateral portions 
of the scalp. Men are much more frequently affected than women, possibly on 
account of the difference in the head-gear of the sexes. It is curious 'that while 
atrophy of the hair of the scalp is the normal occurrence in old age, the hair on 
other portions of the body, as the beard and eyebrows, and also the vibrissas, is 
rather increased in growth in old age. 

3. Alopecia prematura, presenilis, or simplex. In this very common affection 
the process is similar to that in senile alopecia ; but it occurs in younger subjects, 
often beginning between the twentieth and the thirtieth year, and is not preceded 
by grayness of the hair. Usually the baldness begins at the vertex and spreads an- 
teroposteriorly ; but it may begin on the temples at either side ; it is always sym- 
metrical. The process is a continuous one ; as the hairs fall out fewer and fewer 
new ones, of decreasing length and thickness, are produced ; finally lanugo hair, and 
then none at all, grows out. In exceptional cases the course of the affection is quite 
rapid, and baldness ensues in a few weeks or months; usually, however, it takes 
years before that is complete. The skin is left tense, smooth, and shiny, or covered 
with lanugo hair. The secretion of sweat and sebum may be increased ; but many 
cases show no evidences of seborrhea. Both sexes are affected, but males more fre- 
quently than females, and more especially those with sedentary occupations. Not 
infrequently a tendency to the affection runs in certain families. Only the hair of 
the scalp is affected, and many of these cases have strong and luxuriant beards. 

4. Alopecia symptomatica. Alopecia occurs as a symptom of various general 
and local affections in which changes of the hirsute skin take place. It may be 
partial or complete, temporary or permanent. The local affections of the hairy sur- 
face that are accompanied by ulceration or interstitial absorption are not infrequent 
causes of partial alopecia. Thus in the ulcerative syphilides and leprides, with vari- 
ola and folliculitis, there is a direct destruction of the hair-follicles and a permanent 
baldness of the part affected. In favus, from the pressure of the mass of fungus, as 
well as in lupus erythematosus and the non-ulcerative syphiloderm, the same result 
is brought about by interstitial absorption. Seborrhea sicca is a common cause of 
general defluvium of the hair, especially in women ; as also is erysipelas of the scalp. 
Trichophytosis and alopecia areata cause a temporary falling of the hair over the 
areas affected. 

Many general affections are accompanied by a symptomatic falling of the hair, the 



300 ILLUSTRATED SKIN DISEASES-. 

skin sharing in the general nutritive depression of the body tissues, and showing it 
most commonly in atrophic changes of the hair and the nails. This is notably the 
case in syphilis, where a general diffuse falling of the hair occurs as a regular symp- 
tom some three to six months after the infection. The hairs become dry, dull, 
brittle, and loose, and are shed with greater or less rapidity. The resultant alopecia 
may be slight or very well marked, and even the hair of the eyebrows and beard 
may be affected. Very often it falls out more or less completely in irregular patches, 
giving the scalp a characteristic " moth-eaten " appearance. In erysipelas the gen- 
eral affection causes more or less defluvium, in addition to the local action of the 
disease upon the scalp. The infective fevers, typhoid, scarlet, variola, etc., are reg- 
ularly followed by falling of the hair ; and I have seen it occur after major operations 
with prolonged convalescence. In all these cases the hair usually grows out again, 
often with increased luxuriance. 

Symptomatic falling of the hair also occurs with diseases of the nervous system, 
epilepsy, migraine, certain psychoses, and after nervous shocks. I have seen com- 
plete alopecia affecting not only the head, but the eyebrows, eyelashes, mustache, 
beard, the axillary and pubic regions, and the trunk and limbs, occurring very rap- 
idly in consequence of worry and insomnia. Here the hair may or may not grow 
again. 

5. Alopecia pityrodes, alopecia furfuracea, or pityriasis capitis, is perhaps the 
commonest form of baldness, and occurs associated with a chronic seborrhea, the 
influence of which malady in causing atrophy of the hair has been already referred 
to. It occurs at all ages, but begins most frequently between the twentieth and the 
thirtieth year ; males are most often affected, and in them the beard and eyebrows 
are sometimes involved as well as the scalp. It begins as an ordinary dry seborrhea, 
with slight reddening, scaling, and itchiness of the scalp. The scales may be white, 
dry, and composed chiefly of epithelium ; but more commonly they are grayish, 
greasy, and seborrheal. The nutrition of the hairs is interfered with ; they become 
harsh, dry, lusterless, and fall out slowly. After remaining in this condition for 
years, a more rapid falling begins, and baldness soon sets in. It usually commences at 
the sides of the temples and gradually spreads to the vertex ; in women it begins at 
the part. When the baldness is complete the seborrhea ends, and the scalp is left 
thinned, shining, and atrophic, as in the other forms of alopecia. The affection 
occurs in infants, and frequently causes thinning and loss of the hair, but no per- 
manent baldness. 

Etiology. — Alopecia senilis is a physiological change, being a part of the atrophic 
changes of old age. So also is premature alopecia, which is peculiar only in its 
early occurrence. Alopecia adnata is a deformity of unknown origin. Alopecia 
symptomatica is due to the disease with which it occurs ; it occasions either a direct 
destruction of the hair-follicles, or such nutritive depression of the hairy skin that 
the pilous structures fall out. Alopecia furfuracea is caused by the same agencies 



ATROPHIES. 301 

that cause seborrhea, among which may be mentioned neglect of the hygiene of the 
scalp, and the wearing of heavy hats and bonnets. It is possible that direct transfer 
of a contagion in the barber-shops is its essential cause. Lassar and Bishop pro- 
duced an alopecia in the skin of healthy animals by rubbing in an ointment com- 
pounded of the epithelial detritus and hairs of a patient affected with the disease. 
Boeck, Malassez, Balzer, and others have described cocci and bacteria as the etio- 
logical factors. Definite proof of this, however, is still wanting. 

Pathologfy. — In alopecia adnata there is an arrest of development of the pilous 
structures. Schede found in his cases that the hair-follicles were either absent or 
aborted and atrophic, while the other elements of the skin were normal. In the 
senile and premature alopecias there is a fibrous endarteritis of the follicular vessels ; 
the epidermis and derma are thinned and shrunken; and the hair-follicles are atro- 
phied and empty, or contain aborted hairs. Alopecia symptomatica shows atrophied 
follicles and hairs, or complete destruction of the pilous apparatus. In the furfura- 
ceous form of alopecia the corium is atrophied, and its connective-tissue fibers have 
undergone more or less fatty and colloid degeneration ; the sebaceous glands are 
shrunken ; and the hair-follicles are filled with epithelial scales and rudimentary hair. 

Diagnosis. — The general thinning and atrophy of the hair in the first three forms 
of the disease are sufficiently distinctive. In alopecia furfuracea the epithelial char- 
acter of the scales and its symmetrical appearance will distinguish the affection from 
seborrhea sicca, which is asymmetrical and has grayish-white, greasy scales. Tri- 
chophytosis capitis has sharply limited patches with nibbled-off hairs ; and patches of 
ringworm will frequently be found on other portions of the body. Alopecia areata 
has sharply circumscribed patches, at least at first, and the skin is normal, showing 
neither scaling nor induration. 

Prognosis. — The prognosis of alopecia congenita is usually good ; in most cases 
the hair grows in time, though not with the abundance that characterizes the normal 
skin. That of alopecia senilis is bad ; in rare cases only the hair grows again. 
Alopecia prematura, if not too far advanced, can be stopped ; but when the scalp 
has become hide-bound and atrophic, treatment is useless. To determine the prog- 
nosis in individual cases, the hairs that fall out in a day should be collected, and, in 
the male, the number of pointed and uncut as compared with the number of cut hairs 
noted ; in the female, where all the hairs are uncut, those under and over 6 inches 
in length should be counted. If the pointed hairs or those under 6 inches in length 
exceed one quarter of the entire amount, the disease is progressive, and the prog- 
nosis is bad. The prognosis of symptomatic alopecia varies with the cause. If it 
is due to nutritive depression alone it is good; the hair usually grows in as abun- 
dantly or more so than before. If it is due to atrophic changes the prognosis is hope- 
less. Alopecia furfuracea is of fairly good prognosis if it is not too far advanced, if 
atrophy has not set in, and if the cause can be removed. 

Treatment, — Systematic treatment is of importance in most varieties of alopecia, 



302 ILLUSTRATED SKIN DISEASES. 

but more especially in the symptomatic and furfuraceous forms, as well as for pro- 
phylactic purposes in cases where the family history shows a tendency to the early 
advent of baldness. It consists of the use of tonics and all measures calculated to 
improve the nutrition of the tissues in general and of the skin in particular. Nour- 
ishing diet, fresh air, exercise, bathing, etc., the administration of iron, strychnia, 
phosphorus, arsenic, and cod-liver oil, will be found useful. Shoemaker recommends 
the tincture of ignatia in io-drop doses three times daily. Attention to the hy- 
giene of the scalp is of the very greatest importance. This consists essentially in 
the careful combing and brushing of the hair, and the free use of soap and warm 
water on the scalp. The use of heavy and closely fitting head-gear is to be avoided 
as far as possible. 

The local treatment consists in all cases in the endeavor to stimulate the nutrition 
of the hair-follicles by causing a temporary and artificial hyperemia of the skin in 
which they are seated. The thoroughness of the frictions, brushings, and sham- 
pooings by means of which the various applications are applied is of more impor- 
tance than the nature of the special medicament that is used ; for we know of no 
specific drug which increases the nutritive activity of the hair-papillae. In most 
cases the applications are better made with a stiff brush than with the fingers; and 
in all cases they should be vigorously rubbed into the scalp rather than applied to 
the hair. As most of them dissolve and remove from the surface of the scalp and 
hair the fatty substances necessary for their healthful growth, it is well to use a 
moderate amount of vaseline, benne-oil, or a pomade after applying them. 

Alopecia adnata, as a rule, requires no treatment ; the hair grows of itself in the 
course of time. Frictions with green soap or with the green soap tincture (No. 5, 
p. 43), followed by a stimulating application (No. 142, p. 303), may be used if treat- 
ment becomes necessary. Senile alopecia is best left alone ; the condition is almost 
always a permanent one. 

Presenile alopecia is an affection for which we are frequently consulted, and in 
predisposed cases the prophylactic measures above described should be carefully and 
systematically carried out. General treatment is often required ; for there is an 
undoubted connection between the early appearance of baldness and dissipation, 
overwork, worry, etc. Hypodermic injection of -p 2 to -jt of a grain of the muriate of 
pilocarpine has done good in the hands of Schmitz, Schuller, and others. Static 
electricity is recommended by some authorities. In mild cases a bicarbonate-of- 
soda lotion (No. 143, p. 303) should be rubbed into the scalp every day or every 
other day. More advanced cases require stimulating applications of greater power 
(Nos. 142, 144, p. 303). Naphthol or resorcin ointments (No. 37, p. 82, No. 41, 
p. 100, No. 48, p. 105, Nos. 123, 125, p. 243), or the combinations of naphthol and 
sulphur with green soap (No. 46, p. 104, No. 55, p. 115), can be employed. Ihle's 
resorcin lotion (No. 145, p. 303) may be rubbed into the scalp daily with a piece 
of flannel. Tar applications are recommended by Piffard (No. 146, p. 303). The 



ATROPHIES. 



303 



sublimate lotion (No. 148, p. 303) and a 15-per-cent. tannic-acid ointment (No. 147, 
p. 303) are also useful. 



No. J42. Stimulant Lotion. 



ft Tra. capsic. 
Tra. cantharid. 
Spts. colognien. 



aa. 1 part 
8 parts 



No. 144. Quinine Lotion. 



ft Quin. sulphat. 
Spts. vini Gallici 
Aq. colognien. 



1 part 
60 parts 
ad. 100 " 



No. 146. Tifard's Tar Lotion. 



ft 01. rusci 
Ol. lavandul. 
Ol. pini sylvestri 



aa. 1 part 
50 parts 



No. J48. Sublimate Lotion. 



ft Hydrarg. chlor. corn 
Aquas . 



1 part 
500 parts 



No. J50. Naphthol Spirit. 



ft /3-naphthol . 
Alcohol absol. 



1 part 
200 parts 



No, J43. Sodic Bicarbonate Lotion. 



ft Sod. bicarb. 
Aq. dest. 



1 part 
50 parts 



No. 145. Lhle's Resorcin Lotion. 



ft Resorcin. albiss. 
Ol. ricini 
Spts. vini . 
Bals. Peruv. 



No. 147. Tannic-acid Ointment. 



10 


parts 


90 




300 


" 


I 


part 


tit. 
I 


part 


2 


parts 


• 4 


a 



ft Ac. tannic 
01. ricini 
Adip. lanse 



No. J49. Lassar's Sublimate Lotion. 

1 part 



ft Hydrarg. bichlorid 
Glycerini 
Spts. colognien. 
Aquae . 



aa. 300 parts 



No. 15J. Lassar's Salicylic-acid Ointment. 



ft Ac. salicyl. 
Tra. benzoin 
01. bubuli . 



2 parts 

3 " 
100 " 



The treatment of alopecia symptomatica is essentially that of the underlying dis- 
ease. General antisyphilitic treatment, together with the use of the sublimate lotion 
(No. 148, p. 303) or the white precipitate ointment, is appropriate for the luetic alo- 
pecia. Erysipelas, the infective fevers, diabetes, etc., must be appropriately treated, 
while any one of the stimulating applications above mentioned may be used. As a 
rule, the alopecia gets well of itself. 

Alopecia furfuracea is so common a cause of baldness that its prophylactic treat- 
ment in cases affected with seborrhea of the scalp becomes a matter of importance. 
The means to be employed are essentially the same as those for seborrhea (pp. 64, 65), 
and must be used steadily for months, combined with careful washing, combing, and 
brushing of the scalp. In advanced cases the scales should be removed with soap 
and water, or the tincture of green soap (No. 5, p. 43), or borax and water, and the 
scalp and hair then thoroughly rinsed. Any one of the various stimulating applica- 
tions can then be used, Sulphur is a very valuable remedy in this affection. It can 



304 ILLUSTRATED SKIN DISEASES. 

be used as ointment (No. 25, p. 64), applied every night at first, and less often as 
the desquamation lessens. The head should be thoroughly washed every three days. 
The mercurial ointment recommended by Bronson (No. 23, p. 64) and the resorcin 
ointment (No. 20, p. 64) are efficacious. 

The treatment advocated by Lassar is based upon his belief in the parasitic ori- 
gin of this form of baldness. It is somewhat troublesome, but has proved fairly 
satisfactory in my hands. The head is first lathered with strong tar soap for ten 
minutes, and then washed out with first warm and then cold water. The scalp is 
dried, and the sublimate lotion (No. 149, p. 303) applied. Then the scalp is dried by 
rubbing in the naphthol spirit (No. 150, p. 303), and anointed with a salicylic-acid 
ointment (No. 151, p. 303). 

ALOPECIA AREATA, 

Synonyms. — Area Celsi, porrigo s. tinea decalvans, alopecia circumscripta, pelade 
(Fr.), die krcisfleckige Kahlheit (Ger.). 

Definition. — Loss of hair, causing the appearance of one or more circumscribed 
white bald patches of varying size and shape, sometimes spreading to more or less 
complete baldness. 

Symptoms and Course. — Occasionally after a period of general ill health, with 
localized headache and pruritus, but more commonly with no prodromal symptoms 
at all, there appear upon the hairy surfaces of the body one or several areas of 
baldness. The advent of the disease is sudden ; the hair may come out overnight, 
and the denuded patch be discovered by the patient or his friends ; in other cases 
the loosened tuft of hair is accidentally pulled out. The hairs are not broken 
off, as in ringworm ; they fall out in their entirety. The denuded areas are almost 
always round, but they may be elongated or band-shaped ; occasionally they follow 
zigzag or irregular tracks. The site of the alopecia is most commonly the scalp, and 
next most frequently the beard ; other regions, such as the axillae, pubes, and the 
trunk and limbs, are much more rarely affected. In exceptional cases the falling of 
the hair occurs more diffusely ; the areas are not well marked ; and the general 
appearance of the malady on the scalp is like that of alopecia furfuracea. 

The denuded areas in the beginning are usually small, from \ to 1 inch in 
size ; they often spread with rapidity until they have attained a certain size, and 
then remain stationary. One only, or a few, may be present at one and the same 
time ; but not infrequently patch after patch forms, the earliest ones being already 
covered with lanugo hair and progressing to recovery while the latest are appearing. 
Adjacent areas may coalesce so as to form irregular bald spots bounded by curved 
lines. In these composite patches, however, a thin and irregular band of lanugo or 
atrophic hair usually remains to mark the original boundary of the area. Finally, 
in some cases, the number of patches may be so great that complete baldness results. 




TYP03R4VURE. 



COPYRIGHT BY E. B. TREAT 4 CO , N. Y. 



ALOPECIA AREATA. 



PLATE XLV. 



ATROPHIES. 






and pubes, and 

genet 
The 

the hair- 
are distir tppears 

^ome c . There is ah 

no he patches are 

3vable, or stunted 
i 



becomes stroi 
spread raj 

OCCUi 

come 



Gruby, i 
with one 
scribed; a.nd ma> 
microorg 

epid i 



deal In 

heir pei ->< 

the whole of time 

In malt; 

neral and n 
pecia, m< be- 

■ ■ i 
indi\ 

[de 
para 

their point of o 
Ide n 

ntal sho< 

ata occur in 
i 
I he . al factor I obsen 

Robinson, et. 

. and in o ^een de- 

i< eriologist 

e that the disease seems o< 
ribed b; 



ools. Dermat' 
id graduall}-, and are always ac< 
torn- >s, swei. 

Pat f the 

pat' - : changes. There is an infill 

coriu. of the pap ; h new small I an atR 

of the I ts, and the sebaceous gh >vho has ex 

ined i .ss than twenty cases, cone. s is a deep- 







-ECIA ARE. 



PLVTE XLV. 



ATROPHIES. 305 

and all the hair, not only of the head, but also of the beard, axillae, pubes, and the 
general surface of the body, may be lost. 

The skin of the affected areas is first normal, though whiter than usual ; it is en- 
tirely bald, or shows only a few scattered hairs, but the orifices of the hair-follicles 
are distinct ; later on it appears shrunken, thinned, and quite smooth. Sensation is 
usually normal, though in some cases there is anaesthesia. There is absolutely 
no inflammatory action or scaling. In the early stages, while the patches are 
spreading, the hairs at the margins may be readily removable, or stunted and 
atrophic; later on, when the disease is not progressing, they are healthy and firmly 
seated. 

The course of the disease varies a good deal. In benign cases the spots are few 
in number and remain small. After lasting for a number of months new and firmly 
seated hairs begin to grow at their periphery, and they get smaller; in other cases 
a fine lanugo growth appears over the whole patch, which in the course of time 
becomes stronger and pigmented. In malignant cases the patches are numerous, 
spread rapidly, and coalesce, and a general and more irregular falling of the hair 
occurs ; in these instances the alopecia, more especially in children, is apt to be- 
come universal. Relapses are not infrequent in both forms ; recovery takes months, 
but is the rule, especially in young individuals. 

Etiology. — The causation of alopecia areata is still a matter of dispute ; and it is 
possible, as Crocker holds, that there are grouped under this designation several 
distinct diseases, some of which are parasitic and others neurotic in origin. Many 
of the cases seem to point distinctly to the nervous system as their point of origin. 
The preliminary headaches, the sudden onset, the anaesthesia that is sometimes 
present, and the cases reported as following nerve injuries and mental shocks are of 
this category. Mibelli, Pantoppidan, and Joseph have seen alopecia areata occur in 
men and animals after surgical injuries to the cervical nerves. 

Parasites have been described as the etiological factor by a number of observers, 
Gruby, Bazin, Thin, Von Sehlen, Robinson, etc. But their results do not agree 
with one another; in some a bacterium and in others a micrococcus have been de- 
scribed ; and many competent bacteriologists have failed to find any characteristic 
microorganism at all. It is true that the disease seems occasionally to occur in 
epidemics ; such have been described by Voillard and Vincent, Feulard, and others 
as occurring in regiments and schools. Dermatomycoses, however, invariably begin 
slowly, start in distinct foci, spread gradually, and are always accompanied by symp- 
toms of inflammation, redness, swelling, vesiculation, and crusting. 

Pathology. — This also is still a matter of debate. The marginal hairs of the 
patches show atrophic changes. There is an infiltration of the upper part of the 
corium, more especially of the papillae, with new small round cells, and an atrophy 
of the hair-follicles, roots, and the sebaceous glands. Giovannini, who has exam- 
ined sections from no less than twenty cases, concludes that the process is a deep- 



306 ILLUSTRATED SKIN DISEASES. 

seated folliculitis. Regarding the cause of this folliculitis no more can be said than 
has been stated under the etiology. 

Diagnosis. — This is rarely a matter of difficulty. The sudden appearance of the 
bald areas, their rapid extension, their circular form, the absence of nibbled-off hairs, 
scales, and crusts, the smooth and shining skin, with the occurrence only on the hairy 
portions of the body, are sufficiently characteristic. Nevertheless the affection must 
be distinguished from trichophytosis capitis, favus, lupus erythematosus, and the 
baldness caused by burns and ulcerative processes, as well as from the other forms 
of alopecia. Ringworm begins at one point as a small inflammatory papule or 
patch; it spreads slowly; is circular in form; has frayed and broken-off hairs over 
its surface ; shows signs of inflammation, redness, papules, vesicles, crusts, and scales ; 
occurs also on the non-hairy parts; and the fungus can be readily demonstrated in 
the hairs and scales. Chronic cases of ringworm, in which the circular patches have 
disappeared, and in which there is a general alopecia and scaling, are more difficult 
to distinguish ; yet here also the signs of inflammation, and the presence of some 
characteristic broken-off hairs, together with the detection of the fungus, will serve 
to prevent error. In favus there are no circumscribed denuded areas ; the characteris- 
tic sulphur-yellow crusts or powdery scales are present ; the malady is very slow, 
inflammatory, and leaves cicatricial tissue behind ; and the microscope readily reveals 
the fungus in the crusts. Lupus erythematosus is inflammatory, is slow in its course, 
finally causes atrophic changes, and has the characteristic seborrheal scales with plugs 
upon their under surfaces. Baldness from actual destruction of hair-bearing tissue 
should not be mistaken for alopecia areata. Whether caused by a burn, or by an 
ulcerative process such as syphilis, its permanence and the presence of cicatricial 
tissue will serve to differentiate it from the affection under consideration. The gen- 
eral defluvium capillorum that occurs in the early stages of syphilis may be mistaken 
for an aggravated alopecia areata; but there are never any circles, there is a char- 
acteristic " moth-eaten " look to the affected surfaces, and the history and the presence 
of other syphilitic symptoms will elucidate the diagnosis. Alopecia of the senile 
and the premature forms is preceded by grayness and is slow of onset ; it does not 
appear in circles ; it begins at the vertex or on the temples, and gradually spreads ; 
it is usually preceded by a seborrhea; and it takes years for complete baldness to 
be effected. 

Prognosis. — Alopecia areata tends to spontaneous recovery, especially in the 
young; but it takes a long time to run its course, most cases lasting from six months 
to two years. In older individuals recovery often does not take place. The more 
numerous the patches, and the quicker their spread, the worse the prognosis. 
Malignant cases, with general diffuse alopecia of the whole body, are usually of bad 
prognosis. 

Treatment. — Though internal remedies have little or no effect upon the disease 
itself, they are of importance for the general health, which undoubtedly influences 



ATROPHIES. 



307 



the malady. Tonics, fresh air, exercise, baths, especially of salt water, are impor- 
tant agents in the treatment of alopecia areata ; so also are cod-liver oil, iron, phos- 
phorus, arsenic, and quinine. Hypodermatic injections of the muriate of pilocarpine, 
8 to tV grain every five to six days, have been reported to have a very beneficial 
effect upon the disease. The malady tends to spontaneous recovery, but we can do 
much by these means to hasten its course. 



No. 152. Croton-oil Ointment. 

fy 01. tiglii .... 2 parts 

Cer. alb. 
01. theobrom. . . aa. i part 



No. J53. Bulklefs Carbolic-Iodine Application. 
fy Ac. carbolic 



Chloral. 
Iodinii 



aa. p. 



No. 154. Jessner's Carbolic -Sulphur Ointment. 

fy Acid, carbol. 

01. bergam. . . . aa. i part 

Sulphur, sublim. . . 5 parts 

Adip. benzoat . . . 50 " 

The local treatment consists, as in the other forms of alopecia, in the stimulation 
of the nutrition of the scalp ; and any of the stimulating applications recommended 
on p. 303 is appropriate. The epilation of the loose hairs at the margins of the 
patch with the fingers is advisable in most cases. Static electricity has done well, 
in the hands of G. H. Fox, in stimulating the new growth of hair. The local stim- 
ulation must be quite vigorous ; the skin stands it very well in these cases. A favor- 
ite method is to blister the skin of the affected areas with croton-oil or cantharidal 
collodion, dressing afterward with olive-oil. A croton-oil ointment (No. 152, p. 307) 
may be rubbed in in small quantity every five or six days ; twelve to twenty-four 
hours after the application the inflammatory reaction appears. Bulkley recom- 
mends a carbolic-acid and iodine application (No. 153, p. 307) which may be applied 
every other day; Jessner's carbolic-sulphur ointment (No. 154, p. 307) maybe used 
daily. Acetic acid may be painted over the part till the skin whitens, and then 
sponged off with water ; or the stronger water of ammonia may be applied daily to 
the patches for weeks. The various corrosive-sublimate lotions (No. 148, p. 303, 
etc.) may be used, and Lassar recommends his process for the treatment of alopecia 
furfuracea (p. 304). I have found the use of chrysarobin ointment (No. 8, p. 46, 
No. 40, p. 94) a very satisfactory method, more especially when preceded by vigor- 
ous friction with the tincture of green soap (No. 5, p. 43). Our efforts must be 
directed to effecting the greatest possible amount of stimulation that the skin will 
bear, the special means employed for that purpose being comparatively unimportant. 

ATROPHIA PILORUM. 

Defective nutrition of the hairs may cause atrophic changes of various kinds in 
these structures. They consist essentially in a diminution of the size of the pilous 






308 ILLUSTRATED SKIN DISEASES. 

structures, with consequent fracture. We shall consider briefly the conditions 
known as aplasia pilorum propria, fragilitas crinium, and trichorrhexis nodosa. 

1. Aplasia pilorum, monilethrix, pili annulati, moniliform or beaded hairs, Ring- 
elhaare (Ger.), cheveaux moniliformes (Fr.), is a rare condition in which the shaft of 
the hair is not of uniform size, but consists of a succession of thicker dark and thinner 
lighter-colored portions. The thicker portions are normal shaft; the thinner ones, 
one third their size, occur at regular intervals along the entire shaft and contain 
neither medulla nor pigment. The hair-bulbs are usually atrophied. Fracture of 
the hair occurs, probably from slight mechanical causes, at the thinned internodal 
parts, and the fractured ends may be smooth, or frayed-out and brush-like. The 
affection usually begins in early infancy, and may go on to complete baldness; it is 
frequently inherited, and is to be looked upon rather as a deformity than as a dis- 
ease. All the hairy regions of the body may be affected. Its cause is unknown. 
Treatment is of little value, though occasional cases go on spontaneously to partial 
recovery. 

2. Fragilitas crinium, scissura pilorum. Here the hair becomes dry and splits 
either at its end or in its course. It occurs as a symptom in the parasitic diseases of 
the hairy portions of the body, trichophytosis and favus, and occasionally also in dry 
seborrhea and eczema. After various fevers and cachexiae also the hair loses its 
luster and becomes fragile. It is seen as an idiopathic affection from causes, as yet 
unknown, that interfere with the nutrition of the hair. The hair becomes dry, brittle, 
and dull ; and the splitting into two or more filaments may begin at its end and run 
part or all the way to the root, or it may commence at any portion of the shaft. 
The split hairs show a marked tendency to curl up. The affection occurs most fre- 
quently in the scalp, especially in women, and next most frequently in the beard. 
Only a few scattered hairs or a large number may be affected. It is not associated 
with any general affection or any local disease of the scalp. The microscope shows 
the hair-bulb either normal or atrophied, and the medulla of the shaft more or less 
broken up; but there is no other recognizable change. Treatment consists in atten- 
tion to the hygiene of the scalp, more especially by the free use of the comb and 
brush. The split hairs should be cut above the cleft. 

3. Trichorrhexis nodosa or nodositas crinium. Here there occur peculiar nodose 
swellings, involving the entire circumference of the hair at irregular intervals along 
the shafts, and of a transparent and shining grayish hue. When they occur in red 
hair their color is said to be black. From one to five are usually present on a single 
hair, most commonly at its distal end. The hairs themselves are brittle, and 
prone to fracture at the nodes, leaving a brush-like mass of filaments projecting from 
the free end of the structure. The hair is firmly seated in its follicle, and the bulbs 
are apparently normal, as also are the internodal parts of the shaft. The etiology 
of the disease is obscure ; no parasite has been found. The affection occurs almost 
exclusively in the male beard. The most hopeful treatment consists in shaving, and 



i 



ATROPHIES. 309 

the use of the various stimulating applications to the skin from which the hairs 
grow (Nos. 144, 148, 149, p. 303, No. 154, p. 307). 

4. ATROPHY OF THE NAILS. 

Atrophy of the entire structure of the nail or of a portion of it occasionally 
occurs. We shall consider atrophia and leucoma unguium. 

ATROPHIA UNGUIS. 

Onychatrophia, atrophia unguis, or general atrophy of the nail occurs as a con- 
genital or as an acquired condition. In the congenital cases the digits are usually 
poorly developed, the nails themselves being distorted, rudimentary, or absent. The 
hair also is generally defective. The acquired cases arise from traumata, as on the 
feet from the pressure of improperly fitting boots and shoes, and on the fingers from 
injuries of common occurrence in the various trades. They also occur from the action 
of heat and cold ; from chemicals, as with druggists and photographers ; from inflam- 
matory affections of the nail-bed, onychia and paronychia; in the course of various 
internal diseases, tuberculosis, syphilis, peripheral nerve lesions, etc., and after sur- 
gical accidents ; and as a part of many affections of the general integument, psoriasis, 
eczema, parasitic diseases, etc. The nails lose their luster; they may become 
expanded, thinned, and curved, but more frequently they are abnormally brittle, and 
become thickened, split, and furrowed in various directions. They may finally fall 
out. Both the prognosis and the treatment depend upon the cause of the atrophy. 
The only local measure required is the protection of the fragile nails by means of 
leather stalls or rubber finger-tips. 

Leucoma unguium appears not infrequently in perfectly healthy persons, but 
occurs also after the various fevers, nervous affections, etc. White spots or stripes 
occur in the otherwise normal nail, and grow outward with it. They are supposed 
by some to be due to an infiltration of air in the epithelial cells, similar to that which 
occurs in the hair in canities. By others they are thought to be due to a tropho- 
neurosis which causes nutritive changes in the matrix. There is no treatment for 
the affection. 



COSMETICS OF THE SKIN AND HAIR. 



The cosmetic care of the skin and its appendages has usually received but scant 
attention ; yet the subject is of importance, especially to the female half of our 
patients. Its real basis is hygiene ; and the health of so important and vital an 
organ as the skin is a matter of just concern, and one about which the practitioner 
is frequently consulted. The subject includes the proper methods of cleansing and 
caring for the skin, and the means to be employed for that purpose ; the remedying 
of such defects as excessive roughness and dryness, superfluous moisture and oili- 
ness, undesirability of hue and abnormal colorations or discoloration, unusual size, 
form, color, quantity, or implantation of the hair and nails ; and, in fact, the pre- 
vention and treatment of a number of conditions not sufficiently marked to be 
recorded and treated as diseases. Various means are at our disposal for these 
purposes, which may be classified as cleansing agents, stimulating or soothing agents, 
coloring or discoloring agents, and agents for the removal of other abnormalities. 

L CLEANSING AGENTS. 

The first and most important requisite for the health and beauty of the skin 
and its appendages is cleanliness, in spite of the fact that a direct connection 
between uncleanness and dermal abnormalities and diseases can sometimes not be 
recognized. The regular removal of dirt, dust, dried sebum and sweat, and des- 
quamated epithelium is necessary for that proper nutrition, good circulation, and 
normal performance of function of the organ which is essential to its proper appear- 
ance. The chief agent for this purpose is of course water ; and its importance is 
such that the amount in which it is used may almost be taken as the index of 
civilization of an individual or a people. In many cases it is undoubtedly insuffi- 
ciently employed, and we have certainly retrograded in some respects from the 
ablutionary habits of the classical nations. The considerable prejudice that still 
remains against its employment in an amount and with a frequency sufficient to be 
fully effective has some basis in the facts that not all forms of the fluid are suitable 
for every person, and that in some abnormal conditions of the integument its influ- 
ence is distinctly harmful. 

310 



CLEANSING AGENTS. 311 

For cleansing purposes water should be employed warm. Hot water is only 
exceptionally necessary when especially vigorous action is desired ; its continuous 
use is relaxing and enervating, and renders the skin abnormally sensitive to exter- 
nal influences. Hot steam or air, as gotten in the Russian or Turkish baths, are 
rather to be classed as therapeutic than as hygienic and cosmetic agents, though a 
cleansing bath is usually conjoined with their use, and the cold douche or plunge 
with which they usually end counteracts their undesirable relaxing effects. Abso- 
lutely cold water is a stimulant, and falls in the same category. 

The entire surface of the body should be bathed for from five to ten minutes, or 
washed, several times a week, if not daily. For whilst the covered portions of the 
body are not so subject as the exposed ones to contaminations from the atmosphere 
and adventitious agents, evaporation and the removal of excrementitious matter is 
much less free, and all material, fluid and solid, which should normally be cast off 
from the skin remains upon the surface or is kept in close apposition to it by the 
underclothing. Water dissolves and removes the salts, part of the fatty acids, the 
dead epithelium, and much foreign matter ; and by doing so is the most important 
single means that we possess for securing a proper nutrition and a healthy and 
desirable appearance of the general integument. 

An occasional disadvantage of water is dependent upon the fact that it may be 
too hard from the presence of calcium and magnesium salts, and so make the skin 
rough and coarse. If a soft water is not obtainable, the ordinary variety may be 
made suitable by prolonged boiling, or by the addition of a small amount of soap, 
or of soda or potash. Of more importance, however, is the damage that is some- 
times done by water on account of its faculty of causing swelling of the epidermic 
cells by imbibition, which in certain cases may be so marked as to render the skin 
raw and fissured. The greater the length of time during which water acts upon the 
skin the more marked do these undesirable effects become in certain cases ; and 
they may be produced even in insusceptible skins by very long-continued action. 
Hence prolonged baths are not to be recommended as a rule, and thorough drying 
is essential to prevent as far as possible these undesirable effects. Vigorous friction 
with a rough towel not only takes up and removes the last traces of superficial 
moisture, but mechanically removes detritus which has been softened but not carried 
away, and stimulates the circulation in the cutaneous organ. In certain diseased 
conditions, more especially of the inflammatory types, water of any kind has an irri- 
tant effect ; yet even here the addition of a little bran to the fluid will render it 
milder in effect. Washing should be avoided in these cases as much as possible, 
of course ; but even an eczematous skin need not be left dirty, and should not be. 
The cleansing should mostly be done with a bland oil ; the ordinary olive or table 
oil of good quality is usually the most convenient to use. But once every few days, 
or even daily, the part should be well washed with water and a mild soap, care 



312 COSMETICS OF THE SKIN AND HAIR. 

being taken to dry the part thoroughly and apply an oily material thoroughly 
immediately thereafter. 

An excellent method of applying water for cleansing purposes is by means of a 
sponge, provided that this latter is soft, clean, and new. Unfortunately sponge 
rapidly become greasy and is difficult to cleanse ; its interstices become filled with 
detritus and decomposable material ; and no more unsuitable cleanser can be found 
than a sponge that has been some time in use and has been neglected, more espe- 
cially if the skin to which it is applied has any tendency to disease. The loofa, 
the sponge-like dried interior of the fruit of the Loofa ^Egyptica, is to be preferred 
for use upon the general surface of the body. The woody fiber absorbs watei 
readily, and becomes soft ; and it is easier to cleanse and less liable to harbor con- 
taminating elements than the sponges usually employed. 

Water is not in itself injurious to the hair, the wide-spread prejudice to the con> 
trary, especially among females, notwithstanding. The normal amount of fat upon 
the cutaneous surface is doubly necessary upon the hair ; without it the pilous 
structures become dry, lustreless, and brittle, and suffer greatly in appearance. 
This is due, however, not to the water but to the soap, often of a markedly alkaline 
kind, which is employed in conjunction with it, and to the non-replacement of the 
oily material that is abstracted from the scalp and hair. It is safe to say that water 
of the proper kind does not rot the hair or affect the scalp injuriously, and that any 
possible evil effects of the soap employed in conjunction with it can be avoided by 
the judicious use of a bland, oily, or fatty material on the scalp immediately after 
the cleansing. Owing to the very imperfect head-covering universally worn by 
women, their scalps and hair are exposed to every noxious influence ; and no more 
suitable breeding-ground for living infectious material can be imagined. Cleansing 
should be correspondingly frequent ; a thorough Aveekly washing is none too much, 
and will have no ill effect if the precaution mentioned above is employed. 

Brushing and combing are important cleansing agents for the hairy portions of 
the body, though they can only be regarded as adjuncts to washing, which they 
cannot replace. An important point, and one but too frequently neglected, is the 
proper care of the instruments employed for these purposes. This is more espe- 
cially the case since the recognition of the fact that one of the commonest causes of 
baldness is a seborrhcea of infective nature, the etiological factor of which is prob- 
ably transmitted through the medium of the hair-brush. These implements should 
be thoroughly cleansed with hot water, soap, and an alkali at frequent intervals, 
followed by a bichloride or other disinfection and exposure to the sun and air. 

For the more energetic detergent effect upon the skin which is desirable in 
almost all cases, soap must be employed in addition to water in cleansing. Its 
therapeutic action has already been discussed (p. 44). Soap softens, swells, and 
dissolves the epidermic scales, saponifies and renders soluble the fatty materials, 



CLEANSING AGENTS. 313 

and promotes the removal of foreign matter. Its action is therefore chemical as 
well as mechanical. It is essentially a combination of fatty acids with alkalies ; 
and in accordance with the employment of soda or potash we have the hard and 
soft varieties of the substance. Different proportions of fat give us the neutral and 
the superfatted soaps ; and the addition of various drugs give us the medicated 
kinds. 

For ordinary cleansing a pure neutral soap is the best ; and the unscented 
varieties are usually preferable, since the odorous materials are but too frequently 
added to conceal imperfections in the body of the article. A good toilet soap 
should be neutral in reaction, since an excess of alkali is irritant ; it should foam 
readily, showing that the proportion of water and of free fat is not too great ; and 
it should leave the skin soft and flexible. 

More strongly alkaline soaps, more especially of the potash varieties, are better 
cleansers, since they cause greater swelling and solution of the superficial epidermic 
scales, and remove all fatty matter with greater freedom than neutral soaps. They 
are therefore necessarily more irritant ; and whilst they must be employed when 
there is much dirt or detritus present upon the skin, or when larger collections of 
crusts or dead epidermis are to be removed, their use cannot generally be recom- 
mended, and they are very apt to occasion excessive dryness, harshness, roughness, 
and even Assuring of the skin. Green soap, either pure or in the form of Hebra's 
tincture (No. 5, p. 43), is the best known representative of the class, and may be 
employed to advantage occasionally on thick greasy skins with a marked tendency 
to acne. Even here, however, it is too irritant to be used regularly ; it must be 
employed only from time to time, and a bland neutral preparation used in the 
intervals. A still greater detergent action can be gotten by the employment of 
soaps containing sand, or finely powdered pumice-stone, or marble-dust, of which 
several excellent kinds are now on the market. Here the mechanical action of the 
insoluble elements comes into play, and the preparations are to be employed upon 
skins that are hard, thick, badly stained, or affected with indurated acne. From 
their mechanically detergent effects such soaps are very effective as a part of the 
surgical disinfection of the hands and other parts. 

The superfatted soaps, on the other hand, are valuable in cases where a mild 
alkaline or even a neutral soap is irritant ; where the skin is dry and fatless, and 
where conditions of asteatorrhea, keratosis, and ichthyosis prevail. Unna has given 
a formula for a soda soap of this description (No. 155, p. 314), in which four parts 
of the fat remain unsaponified, and which is very valuable. The excess of fat 
leaves the alkali but little room for action. All soaps of this class, however, have 
the disadvantages of being unattractive in odor and appearance, and of not keeping 
well ; for the fat readily becomes rancid. 

Occasionally we meet with skin which will not tolerate even the mildest soaps, 



314 



COSMETICS OF THE SKIN AXD HAIR. 



more especially upon the face ; though such instances are rarer than is usually sup- 
posed, and the use of an improper variety of the article is usually the reason for the 
supposed intolerance. Here the pure fats and oils must be employed for cleansing 
purposes ; at the same time they tend -to render the skin smooth, soft, and pliable, 
and improve its nutrition. Milk is a favorite agent in these cases, or olive-, benne-, 
or almond-oil may be employed. They are best applied -by means of large pledgets 
of cotton, since cloths and sponges rapidly become foul and contaminated when 
used for this purpose. A much more thorough cleansing than is usually supposed 
possible can be effected, more especially if the milk or oil is employed warm and 
sufficient friction is applied. Adeps lanae or lanolin is perhaps still better than the 
agents mentioned above, more especially in the form of an emulsion (No. 1 56, p. 314). 
All these fatty agents are contraindicated in greasy seborrheal skins showing an 
abundance of comedoes. Here glycerin may be substituted for soap as the cleansing 
agent, as in the paste recommended by Hager (No. 157, p. 314). 



No. 155. Sapo Super adiposus. 



No. 156. Lanolin Emulsion, 



Beef tallow 


. 59.3 parts 


3 Adeps lanae 


. 


19 parts 


Olive oil . 


. 7-4 " 


Borax 


. 


1 part 


Potash lye (28 Baume) . 11. 1 " 


Aq. rosae . 


• 


1000 parts 


No. 157. Hager s 


Glycerin Paste. 


No. 158. Toilet Water. 




Pulv. tragacanth . 


30 parts 


5 Boracis 


, 


1 part 


Aq. rosae 


70 " 


Aq. rosae 


. 


5 P arts 


Glycerini 


. 125 " 


Aq. Coloniensis . . 


. 


10 " 


Tinct. benzoini . 


. 30 « 


Aq. distil. . 


. 


no " 


01. aurant. flor. . 


1 part 









Alcohol greatly diluted, or bay-rum or cologne water in strengths of 5 to 10 per 
cent., as found in the better class of toilet-waters, are excellent cleansing agents, dis- 
solving and removing much of the foreign matter that maybe present upon the skin. 
As these waters, however, are very liable to contain ingredients which are harmful 
to the skin, they had better be prescribed. No. 158, p. 314, is a useful formula. The 
addition of a little borax increases the detergent effect, and it is often advantageous 
to add a small amount of an oil soluble in alcohol to the mixture to prevent a too 
great drying of the skin (No. 159, p. 315). 

Alkalies are usually employed in the form of one of the alkaline soaps mentioned 
above, but they may be used as washes, and they form the basis of many of the 
proprietary articles recommended for cosmetic purposes. Caution must be used in 
their employment, since many of them tend to render the skin dry and rough and 
the hair brittle. Borax is one of the best and is harmless, and may be employed 
even in concentrated solution anywhere. Formulae Nos. 160 and 161, p. 315, or 
the plain alkaline lotion, No. 67, p. 135, may be used. When a still stronger alka- 



STIMULATING AGENTS. 



315 



line effect is desired a little of the Detergent Solution (No. 162, p. 315) may be 
added to the wash-water. 

Acids are usually found in the form of the toilet vinegars, which are especially 
useful to remedy excessive secretion or abnormal decomposition of the sweat, and 
to keep parts so affected pure and sweet. Among the most useful of these are the 
Cologne Vinegar (No. 163, p. 316) and the Aromatic Vinegar (No. 164, p. 316), to 
be employed diluted. Boric acid is efficient and harmless, and can be used when- 
ever an application of this nature is indicated. 



No. 159. Face Lotion. 



^ 01. ricin 

Tinct. benzoin 
Spts. Colonien. 
Spts. vini 



1 part 

2 parts 
8 " 

25 " 



No. J6J. Borax Lotion No. 2. 

B Kali carbon 5 parts 

Boracis . . . . 10 " 

Aq. Colonien. . . . 40 " 

Aq. rosae . . . . 80 " 



$ 



$ 



No, J60. Borax Lotion No. 1. 



Sod. carb. 

Boraci 

Aq. 



rosEe 



1 part 

5 P arts 
200 " 



No. 162. Detergent Solution. 

Potassii carbon. . . . 1 part 

Tinct. benzoini ... 6 parts 

Aq. rosee . . . 7 " 



2. STIMULATING AGENTS. 

These are not very frequently employed for purely cosmetic purposes, save on 
the scalp, though they are useful when the skin is pale and anaemic, and when 
deficient muscular action seems to be the cause of glandular congestion and the 
various lesions of acne and comedo. Chief among them are massage and friction, 
both of whichrare best done in conjunction with some bland oil. Pure almond-, 
benne-, or olive-oil is usually to be preferred ; but the various cold creams may be 
employed, or one of the lanolin preparations (Nos. 165, p. 316, 156, p. 314) may 
be used. A soap is sometimes preferable. Cold or hot water alone, or an alcoholic 
lotion (No. 159, p. 315) or soap essence (No. 166, p. 316), may be used. Very 
eligible for this purpose also is the green-soap tincture (No. 45, p. 43), though it 
must be employed well diluted to prevent undue irritation. The combination of a 
mild alkali with glycerin is often a desirable preparation to employ for frictions and 
massage ; a good formula is the borax-soap spirit (No. 167, p. 316). 

Stimulant applications are commonly employed upon the scalp, and sometimes 
upon the bearded portions of the face when the pilous growth is deficient. Bald- 
ness, especially in its slighter forms, is certainly increasing in frequency in males ; 
and it is commoner in females than is generally supposed, though usually more 
successfully hidden from sight. We need not inquire whether the wide-spread 



316 



COSMETICS OF THE SKIN AND HAIR. 



contagious seborrhea, which is the commonest form of dandruff and which is com- 
municated mostly through the barber-shops, or the prevalent custom of wearing 
hats that encircle the head with a tight rim and thus interfere with the circulation 
of the scalp for large portions of the day, is the cause of the increasing tendency to 
the early development of alopecia. Undoubtedly, however, the general disuse 
of the oily applications that formed an essential part of the hair toilet of our ances- 
tors is responsible to some degree, at all events, for the deficient nutrition, imperfect 
growth, and early decay of the pilous structures. 



No. 163. Cologne Vinegar. 



No. 164. Aromatic Vinegar. 



]J Acid. acet. cone. 
Aq. Colonien. 



No. 165. Massage Ointment. 



i part 


5 


Tinct. rosmarin. 


1 part 


30 parts 




Tinct. caryophyl. 


1 " 






Tinct. lavandulae 


2 parts 






Camphorae . . 


180 " 






Acid. acet. cone. 


1000 " 






No. J66. Soap Essence. 






5 


Sapon. alb. 
Aq. rosae 




. 1 part 




Aq. naphae . . 


aa. 1 part 






Spts. vini rect. . 


4 parts 



§, Adeps lanae 
01. theobromae 
01. amygdal. dulc. 



Under the headings of seborrhea (p. 64) and alopecia (p. 301) will be found 
the general directions for the treatment of these conditions. The various sulphur 
and resorcin applications (Nos. 20, 24, and 25, p. 64), and the antiseptic and stimulant 
lotions (Nos. 142, 144, 145, 149, etc., p. 303), are often useful when deficient hairy 
growth is to be stimulated. The long-continued employment of the stronger ones 
among them, however, is not advisable, since they may render the hairs brittle, 
and even alter it in texture and color. This is especially the case with those con- 
taining alcohol and alkalies. 



No. 167. Borax Soap Spirit. 



No. 168. Bichloride Hair Wash. 



^ Boracis 

Spirit, vini rect. 
Glycerin 
Sapon. kalin. 



1 part 
50 parts 



aa. 100 



5 Hydrarg. bichloridi 
Glycerini . 
Spirit, colon. 
Spirit, myrciae . 



1 part 
100 parts 



No. 169. Quinine Spirit. 



. aa. 1500 
No. 170. Stimulant Hair Wash. 



IJ, 01. sabinae . 
Tinct. quinae 
Spirit, vini Gall 



1 part 
50 parts 
100 " 



3 Tinct. cantharid. 
Tinct. gallar. 
Aq. Colonien. 



1 part 
5 parts 
50 " 



As a general stimulant to the scalp and hair there is no more generally useful 
application than the bichloride wash (No. 168, p. 316) or the quinine spirit. 
Cantharides is also commonly employed, as in the stimulant hair wash (No. 170, 



SOOTHING AGENTS. 



317 



p. 316). It is of importance, however, to use an oily application after these irritant 
and desiccating preparations, and for that purpose nothing is better than the ointment 
or oil given under formulae Nos. 171 and 172, p. 317. 



No. J7J. Stimulant Hair Ointment. 

5 Balsam. Peruv. 

Ungt. simplic, s. petrolati 



No. J 72. Stimulant Hair Oil. 



1 part 


§. Acid, tannic. 


• 


• . i part 


50 parts 


01. amygdal. 


• 


• .10 parts 




Spirit, vini rect. 


• 


• q. s. ad solut. 



3. SOOTHING AGENTS. 

These are required when the skin is roughened, irritated, and hypersemic, and 
shows a tendency to undergo inflammatory reaction under the influence of slight 
external irritants. The most important of them are the various fats and oils, the 
use of which renders the skin supple, smooth, clean, and glossy, makes it less sus- 
ceptible to atmospheric and other noxious influences, and undoubtedly improves its 
nutrition and appearance when properly employed. The general use of fats for 
inunction, especially after the bath, was common in the ancient world ; and it would 
undoubtedly be of benefit if it were still employed for that purpose. 

Lard is the commonest fat that is employed for inunction purposes ; but it has 
various disadvantages even when combined with benzoin and other preservatives. 
Like tallow and beef marrow, it is very prone to turn rancid ; and its peculiar odor, 
even when corrected by the addition of an essential oil, is very evident when it is 
employed in considerable quantity and over a large surface of the body. One of 
the various bland ointments (Nos. 26, p. 70, 68, 69, p. 135), or the glycerin cream 
(No. 173, p. 317), or the adeps lanae cream (No. 174, p. 317) is preferable to the 
pure fats. 



No. 173. Glycerin Cream. 



No. 174. Adeps Lance Cream No. I. 



5, Cetaceum . 


■ • 


. 13 parts 


3 


Tinct. benzoin 


Glycerini 








Petrolati . 


Aq. rosse . 


• 


. aa. 20 " 




Adip. lana? . 


Paraffin . . 


• 


. 10 " 






01. amygdal. . 


• 


. • 50 " 






01. rosae 


. 


. q. s. 






No. 175. 


Inunction Oil. 




No. J 76. Adej 


Yp 01. amygdal. . 


• 


. 1 part 


3 Adip. Ian. 


01. olivae . 


• 


. 5 parts 




Vasehm 


01. odorat. . 


• 


. q. s. 




Aq. calcis 



1 part 
10 parts 
20 " 



5 parts 
. 10 " 
20-60 " 



Better still are the fluid oils, especially olive and almond, which are best 
employed both for general inunction and local soothing in mixtures suitably flavored 
and scented (No. 175, p. 317). Lanolin, though not a true fat, acts upon the skin 



318 



COSMETICS OF THE SKIN AND HAIR. 



in a similar manner, and may be used as the adeps lanae cream No. I (No. 176, 
p. 317) or the lanolin cream (No. 177, p. 318). It is sometimes desirable to employ 
the fat in more solid form ; in which case Bernatzik's crystal pomade (No. 178, 
p. 318) is eligible. 



No, 177. Lanolin Cream. 



No. 178. Bernatziks Crystal Pomade. 



R Lanolin . 
01. amygdal. 
Vanillin . 



3 parts 
1 part 
q. s. 



R 



Cetacei . . 
01. ricini 
01. amygdal. . 
01. odorat. 



12 parts 
64 " 

20 " 
1 part 



No. 179. White Face Powder. 



No. 180. Almond-meal Powder. 



R Magnes. carb. 
Zinci oxidi . 
Talc, venet. . 
01. millifl. . 



1 part 
7 parts 

12 " 

q. s. 



R Farin. amygd. decort. 
Rad. irid. pulv. 
Ess. citri 
Ess. amygdal. 



60 parts 
5 " 



aa. 



The various powders, of which those composed of starch, talcum, and the car- 
bonate of magnesia are the best, may be applied as soothing and cooling applica- 
tions to the skin, and are largely used in summer for that purpose. The zinc dust- 
ing powder (No. 18, p. 61) can be employed, being but very slightly astringent, as 
also can the white face powder (No. 179, p. 318) and the almond-meal powder 
(No. 180, p. 318). 



No, 181. Glycerin Cold Cream. 



No. 182. Delay's Pomade. 



R Amyli 

Aq. rosae . . . aa. 1 part 
Glycerini . . . .25 parts 
01. rosae . . . . q. s. 


R Tinct. benzoin 
Bals. Peruv. . 
01. amygdal. dulc. 
Axung. . 


• • 

• • 

• • 
• 


1 part 

2 parts 

4 " 

50 " 


No. 183. Rose Pomade. 


No. 184. Brillianline. 




R 01. rosse 1 part 
01. amygdal. dulc. . . 30 parts 
Medull. oss. bovis . . 150 " 


R 01. aeth. flor. aur. . 
01. ricini 
Spirit, vini rect. . 


• • 

• • 
e 


1 part 
30 parts 

35° " 


No. 185. Hair Oil. 






R 01. amygdal. amar. 
01. flor. aurant. 
01. jasmin. . 
01. amygdal. dulc. 


1 part 
. 30 parts 
. 60 " 
• 35° " 







Glycerin in proper dilution is very valuable for soothing purposes, though it 
does not agree with all skins. It may be employed in the form of the glycerin 
cream (No. 173, p. 316) or the glycerin cold cream (No. 181, p. 318). 

The various pomades and hair oils may be considered here, though many of 
them are stimulating rather than soothing agents, and tend to increase the growth 



COLORING AGENTS. 



319 



of the hair. They are made of various mixtures of solid and fluid fats, to which 
coloring and odorous materials are usually added. Their use in moderation is to 
be advocated, more especially since a proper employment of soap and water to the 
scalp for cleansing removes the natural fat more rapidly than it is reproduced. 

Lard is the usual basis of these applications, and is apparently just as good as 
the marrow or bear's fat that was formerly employed. Vegetable oils are employed 
to make the hair oils ; and the addition of wax, spermaceti, etc., gives us the solid 
stick varieties. Nos. 182 (p. 318), 183 (p. 318), 184 (p. 318) are suitable formulas 
of solid and fluid preparations of this kind. 



4. COLORING AGENTS. 

These are occasionally required to hide excessive pallor, sallowness, darkness, 
or redness of the complexion, in cases of jaundice, to conceal the local discolora- 
tions of leucoderma, or the local pigmentations of ephelides, chloasmata or no&vi, 
or to improve the hair. In a general way their use is objectionable, and some of 
the agents employed are injurious to the skin. But they are sometimes necessary, 
and are used to a greater extent than is generally supposed ; henee they require 
some consideration here. 

White face powder is commonly employed to some extent by females, more 
especially in the hot weather ; and here, if of the proper kind, it does have the good 
effect of cooling and soothing the skin, drying off the superabundant moisture, and 
preventing the disagreeable oiliness to which the brunette complexion especially is 
so liable at that time. A pure powder of rice, talcum, or carbonate of magnesia 
is perfectly harmless ; unfortunately many of the commercial preparations contain 
mineral ingredients of which that cannot be said. All such as contain lead or bismuth 
should be rejected, though a small amount of zinc oxide does no harm and improves 
the covering properties of the preparation. Perhaps a simple mixture of starch and 
talcum (No. 186, p. 320) or the magnesia powder (No. 187, p. 320) is the best. 

A flesh tint can be imparted to either of these powders by the addition of a 
very little carmine, or No. 188, p. 320, can be used. As a rule, however, coloration 
of this kind is better done with one of the fluid or ointment preparations mentioned 
below. 

Fluid coloring agents are sometimes employed, the princess water (No. 189, 
p. 320), among others, enjoying a considerable vogue. It is to be applied with a 
brush after shaking, and the sediment thoroughly rubbed into the skin with a cloth. 
Carmine may also be applied in this form, a little rubbed up in glycerin being 
applied to the part. 

White salve preparations are rarely employed ; and the ointment form is the 



320 



COSMETICS OF THE SKIN AND HAIR. 



most eligible one for the red coloration. Either of the pink pigments (No. 190, 
p. 320, 191, p. 320) may be used, being applied by means of a cloth. 

Dyes for coloring the hair are sometimes required in cases of premature or senile 
blanching, and they will always be used to some extent by females in accordance 
with the dictates of caprice or fashion. Several formulae for the preparation of 
black and brown hair dyes, together with details of the method, will be found 
under the heading of canities (Nos. 135 to 141, p. 297). The vegetable dyes are 
the most harmless. A serviceable though temporary dye can be made from the 
fresh juice of unripe walnuts, giving a dark brown color ; and henna, obtained 
from the leaves of the Lawsonia inermis, gives a reddish dye which can be made 
darker by the subsequent employment of alkalies, and removed by means of acids. 
Neither of these substances is much used nowadays, however, to darken the hair, 
pyrogallo being the only agent of organic nature employed (Nos. 135 and 141, p. 297). 



No. 186. Face Powder. 



No. J 87. Magnesia Face Powder. 



5 Amyli trit. 
Hale, venet. 



aa. 



p.e. 



No. J88. Carmine Face Powder. 



5 Carmine opt. 
Talc, venet. 



1 part 
100 parts 



5 



No. J90. Pink Pigment No. I. 

5 Carmine 1 part 

Spermaceti .... 5 parts 
Talc, venet. . . . 100 " 



5 



Magnes. carb. . 




1 part 


Zinci oxidi . 




5 parts 


Talc, venet. . 




12 " 


01. millifl. . 




q. s. 


No. 189. Princess Water. 




Cerussa . . 




5 parts 


Talc, praecip. 






Magnes. carb. 


aa. 


3 " 


Tinct. benzoin . 




1 part 


Aq. rosge 






Aq. Colonien. 


aa. 


75 P arts 


No. J9J. Pink Pigment 


No. 


2. 


Carmine . . . 




1 part 


Ungt. simplic. 




100 parts 



The inorganic or mineral dyes are more commonly used, as the nitrate of 
silver and the bichloride of mercury in formulae 136, 137, 139, 140, p. 297. The 
hair both of the head and the beard should be thoroughly washed before applying 
any of these preparations, since fatty substances containing sulphur are liable to 
change the inorganic and mineral materials employed. The dye itself should be 
applied by means of a tooth-brush, entire strands from their roots to tips being sepa- 
rately treated, and the surrounding skin and the fingers being protected by means 
of rubber coverings or coating the surface with glycerin or oil. 

To produce the lighter blond tints in the hair peroxide of hydrogen is the 
material usually employed. It should always be used fresh and with caution ; the 
tint depending upon the amount employed and upon its concentration. 



DECOLORING AGENTS. 821 

Any one of these dyestuffs must be reapplied at regular intervals, dependent 
upon the rate of growth of the hair. None of them penetrate below the level of 
the skin, so that it is not possible to dye the part of the hair shaft which will rise 
above the surface during the days following the application. The scalp hair needs 
redyeing every two or three weeks ; that of the beard and mustache, which grows 
more rapidly, every eight or ten days. 

A word of caution as to the employment of these various hair dyes is not out of 
place. Many of them, more especially the mineral varieties, have an injurious effect 
upon the pilous structures ; their continued employment renders the hair dry and 
brittle, and apparently effects a chemical change in the shaft itself. Unless great 
care is taken in making the applications, unexpected and undesired color effects are 
sometimes obtained. Some of them stain the skin as well as the hair. Over and 
above all these results, however, they sometimes exert a directly irritant effect 
upon the skin of parts even remote from the site of application. Erythematous, 
papular, and pustular dermatites affecting the scalp and the whole face have been 
noted ; and in Paris during the past year (1901) have been sufficiently frequent to 
lead to official notice and condemnation of the materials employed in some of the 
commercial dyes. 

5. DECOLORING AGENTS. 

But few of these come under the heading of articles for ordinary cosmetic use ; 
if the abnormal coloration cannot be hidden by the ordinary powders and salve 
recommended above (Nos. 186, 187, p. 320, etc.), the chloasmata, lentigines, and 
pigmentary naevi that are their cause are objects for the medicinal treatment which 
is detailed under the headings of these affections. The peroxide of hydrogen in 10 
to 20 per cent solution is perhaps the safest bleaching agent for domestic use. 



6. AGENTS FOR THE REMOVAL OF OTHER ABNORMALITIES. 

The removal of naevi, verrucse, callosities, etc., belong to the medicinal rather 
than to the cosmetic chapter, and have already been dealt with under their appro- 
priate heading. Methods for the radical removal of abnormal hair will be found 
under hirsuties ; there remains only to mention the depilatories, the use of which is 
sometimes advisable, more especially in females. 

Palliative treatment of hirsuties is sometimes necessary in cases where radical 
treatment by electrolysis (p. 257) is not possible ; and depilatory pastes are better 
for this purpose than the razor, since they are easier of employment, need not be 
used so often, and remove the hair to a considerably greater depth than does mere 
ablation by shaving. The formula for one of the best of these, recommended by 



>22 



COSMETICS OF "THE SKIN AND HAIR. 



Duhring, will be found on page 257 (No. 130; together with the method of its 
employment. One of the most ancient is the Rusma employed in Oriental harems 
to destroy pubic and axillary hair (No. 192, p. 322). It is applied by means of a 
spatula, left in situ for ten minutes until dry, scraped off, and the skin then washed 
and powdered. Pastes made of the sulphydrate of calcium or sodium or of barium 
(Nos. 193, p. 322, 194, p. 322) are to be employed in the same manner ; but prepa- 
rations containing orpiment should not be left on so long, some two to five minutes 
sufficing (Nos. 196, 197, p. 322, 198, p. 322). Amongst the least irritating of 
them all is Boettger's depilatory (No. 199, p. 322), which is therefore most suitable 
for the face and where light lanugo hair is to be removed. 

No. 192. Rusma Depilatory Paste. No. 193. Redwood's Depilatory. 

B> Yellow sulphide of arsenic . 1 part B Barii sulphurat. solut. concentr. 1 part 

10 parts Amyli . q. s. ut f. pasta 



Unslaked lime 
M. S. Boil. 



No. 194. Rondel's Depilatory. 

B Sodii hydr. sulph. . . 1 part 

Calc. caust. pulv. 

Amyli . . . . aa. 5 parts 

To be rubbed into a thin paste with water 
for use. 

No. 196. Neumanns Depilatory. 

B Orpiment 1 part 

Amyli .... 3 parts 

Calc. hydrat. . . . 5 " 

Aq. calcis q. s. ut f. pasta mollis. 

No. 198. Depilatory Water. 

B Orpiment .... 

Calc. viv. .... 
Coque c. 

Liq. potas. caust. . 



No. 195. Depilatory Powder. 

B Sodii sulphid. 1 part 

Cretae prsep. ... 3 parts 



No. 197. Debay's Depilatory. 

B Orpiment 1 par: 

Pulv. calc. caust. . . .8 parts 
Pulv. irid 16 " 

No. 199. Boettger's Depilatory. 



1 part 


B Essent. citr. 


1 part 


2 parts 


Amyli 






Ungt. glycerini . . aa. 


4 part: 


2 " 


Calc. hydr. sulph. in aqua 


38 " 



INDEX. 



Abrasions 

Acarina 

Acarus folliadorum 

Acants scabiei 

Achorion Schonleinii 9c 

Achromia 

Acne 

atrophica 

bromata 

cachecticorum 182, 

hypertrophica 

indurata 

inveterata 

medicamentosa 

necrotica 

papulosa 

picealis , 

punctata 

pustulosa 

rosacea 

syphiliticum 

varioliformis 

vulgaris 

Acne 

miliaire 

ponctuee 

rose'e 

varioliforme 

Actinomycosis 

Adenoma 

Adeps Lanse Cream 

Adipoma 

Albinism 

Albinismus 

A Igidite progressive 

Alkaline Lotion 

Alopecia 

adnata 

areata 

circumscripta 

congenita 

furfuracea 

pityrodes 

prematura 

presenilis 

senilis 

simplex 

symptomatica 

syphilitica 201, 



FAGE PAGE 

36 Alum Dusting Powder 58 

116 Anatomical tubercle 184 

66 Anatomy of the skin 13 

118 Anderson's Hair-dye No. 1 297 

, 98 Anderson's Hair-dye No. 2 297 

293 Anemias 74 

228 Angio-elephantiasis 274 

229 Angioma 273 

230 cavernosum 273, 274 

229 Anidrosis jq 

229 Anthrarobin 47 

229 Anthrax 175 

229 Antiseptic Mouth Wash 209 

230 Aplasia pilorum 30S 

229 Area Celsi 304 

228 Aristol 47 

230 Arrectores pilorum 17 

228 Arsenic 45 

229 Arsenic Solution 220 

233 Asiatic Pill 46 

197 Asteatosis 69 

229 Astringent Mouth Wash 209 

228 Atrophia cutis 286 

228 maculosa et striata 287 

67 neuriticum 287 

65 pilorum 307 

233 senilis 286 

254 unguis 309 

227 Atrophies 28b 

276 Atrophoderma 286 

3*7 neuriticum 287 

268 Atrophy of cutis and subcutis 286 

293 of hair 298 

293 of nails 309 

291 of pigment 292 

135 of skin 286 

298 Atropia Pills 78 

298 Anssatz 215 

304 Bacillus anthracis 175 

304 lepra 217 

298 Baldness 298 

300 Balggeschwulst 68 

300 Barbados leg 251 

299 Barber's itch 105 

299 Bartfinne . . . . , 236 

299 Bartjlechte 105 

299 Baths 41 

299 Beaded hairs 308 

202 Black Wash 214 

437 



438 



INDEX. 



PAGE 

Blackheads 65 

Bliisclien 35 

Blasen 35 

Blasenansschlag 145 

Blattern „ 89 

Webs 35 

Blood-vessels of the skin 16 

Blutfleckenkrankheit 83 

Blutgewdchs 280 

Blutschwar 1 73 

Boil 1 73 

Boracic-acid Ointment 74 

Borax Lotion No. 1 315 

Borax Lotion No. 2 315 

Borken 37 

Brandschwar 175 

Brandy nose 233 

Bromidrosis 57, 59 

Bronson's Mercurial Ointment 64 

Bulkley's Carbolic-Iodine Application 307 

Bulkley's Lotion ." 261 

Bullae 35 

Bulks 35 

Burn 161 

Burs, dental 51 

Butterfly lupus 222 

Cade-Sulphur-Green Soap Ointment 225 

Calamine Lotion 137 

Callositas 244 

pedis 245 

Callus 244 

Calomel Powders 210 

Calomel Suspension 46 

Calvities 298 

senile 299 

Camphor-Naphthol 220 

Cancer 277 

en cuirasse 277 

Cancroid 278 

Cancroide 277 

Canities 293, 295 

Carbolic Lotion 56 

Carbolic Spirit 78 

Carbunculus 175 

Carcinoma 277 

lenticulare 277 

tuberosum 277 

Carron-oil 165 

Caustics 45 

Chancre 187, 190 

hard 187 

non-infecting 1 70 

soft 1 70 

Chancrelle 1 70 

Chancroid 1 70 

Cheiropompholyx 144 

Cheloid 265 

Cheveaux moniliformes 308 

Chicken-pox 91 

Chilblains 73, 162 

Chloasma 262 

caloricum 262 

symptomaticum 262 

traumaticum 262 

uterinum 262 



Chloral-Camphor Ointment. . 

Chloral Lotion 

Chromidrosis 

Chromophytosis 

Chrysarobin , 

Chrysarobin Collodion 

Chrysarobin Ointment 

Chrysarobin Ointment Comp. 

Cicatrices 

Cicatrix 

Cilia 

Cinnamonic-acid Injection. . . , 

Classification 

Clavus 

Cocaine Ointment 

Coil-glands 

Collemplastra 

Combustio 

Comedo 



extractor 

Condyloma acuminata . . . 

lata , 

Cooling Salve 

Copper Oleate Ointment 
Cor , 



Corium 

Corn 

Come de la pean 

Cornu cutaneum 

Cosmetics of skin and hair 

Conperose 

Cowpox 

Crabs 

Cradle crust 

Crocker's Lead Thymol Ointment. 

Croton-oil Ointment 

Cro-Ates 

Crusts 

Curettes 

Cuticle 

Cutis laxa 

Dartre rongeante 

Deflnvium capillorum 

Demodex folliculorum 

Depilatory Powder 

Depilatory Water. 



Dermatite polymorphe prurigineuse a pousse'es suc- 
cessive! 

Dermatitis 

ambustionis 

calorica 

cathode-ray 

congelationis 

contusiformis 

exfoliativa 

hemorrhagica 

herpetiformis 

medicamentosa 

parenchymatosus 

traumatic 

venenata 

Dermatol 

Dermatomycoses 

Dermatomycosis barbae 

favosa 



7° 
78 
60 

113 

47 
108 

94 
46 

38 
264 

26 
181 

52 
246 
288 

21 

43 
lbi 

65 
5° 
248 
194 
135 
105 
246 

15 
246 
247 

247 
310 

233 
90 

124 
62 

183 

307 
37 
37 
50 
14 

288 

177 
298 
66 
322 
322 

149 

159 
161 
161 
166 
162 
166 

152 
166 
149 

163 
160 
160 
163 
47 

06 
105 

9* 



INDEX. 



439 



PAGE 

Dermatomycosis furfuracea 123 

marginata 1 10 

Dermatomyomata 272 

Dermatosclerosis 289 

Dermatosyphilis , 190 

Dermatozoa 115 

Diachylon Ointment 136 

Diagnosis , 32 

Diascopy 137 

Dissection tubercle 184 

Diuretic Mixtures 134, 158 

Duhring's Arsenic Mixture 158 

Duhring's Depilatory 257 

Duhring's Morphine Collodion 144 

Duhring's Poison-ivy Lotion 165 

Duhring's Staphisagria Ointment 124 

Dysidrosis 144 

Ecthyma 172 

syphilitica 196 

Eczema 125 

acutum 128 

barbae 130 

capitis 1 29 

chronicum 129 

crustosum 129 

erythematosum 126 

faciei 129 

genitalium 130 

impetiginosum 128 

intertrigo 129 

madidans 129 

manuum 130 

marginatum 1 10 

papulosum 127 

pustulosum , . . . . 128 

rubrum . . . , 129 

seborrheicum 131 

squamosum 129 

tuberculatum 219 

unguium 131 

verrucosum 1 29 

vesiculosum 127 

Electrolysis 49 

Elephant leg 251 

Elephantiasis 251 

Arabum 251 

glabra 252 

Grsecorum 215 

papillosa 252 

tuberosa 252 

verrucosa 252 

vulvas 253 

Elephantiasis 251 

Ephelides 261 

Epidermis 14 

Epilating forceps 51 

Epithelial cancer 277 

Epitheliom 277 

Epithelioma 277, 278 

discoid 279 

flat 279 

fungating 282 

infiltrating 279 

molluscum 254 

of lip , . , . . 281 



PAGE 

Epithelioma of penis 279 

papillary 280 

tubercular 279 

Epitheliomatosis, eczematoid 281 

Epitheliome 277 

Epizoa 116 

Erbgrind 96 

Erysipelas 167 

ambulans 1 1>8 

bullosum 168 

chronic 1 69 

crustosum 168 

gangrenosum 168 

migrans 168 

perstans 168 

vesiculosum 168 

Erysipele 167 

Erythema annulare 139 

bullosum 139 

caloricum 72 

exudativum multiforme 139 

exudativum polymorphum 139 

figuratum 1 39 

gyratum 139 

infantilis 72 

multiforme 139 

nodosum 166 

papulatum 139 

scarletiniforme 73 

simplex 71 

solare 72 

symptomaticum 72 

syphiliticum 192 

traumaticum 72 

tuberculatum 139 

venenatum 72 

Erytheme 71 

?ionenx 1 66 

polymorphe 139 

Erythrasma 1 15 

Etiology 38 

Excoriations 36 

Face Lotion 315 

Face Powder 320 

Falx 28 

Fatty tumor 268 

Favus 96 

capitis 97 

corporis 97 

unguium 97 

Fettgeschwiilst 268 

Ee iter rose 142 

Fever-sore 141 

Fibroma 267 

molluscum 267 

Filaria sanguinis 251, 253 

Eisehschuppenkrankheit 241 

Fish-skin disease 241 

Fissures 37 

Flechte, fressende 177 

scheerende 101 

Flecke 34 

Fleckenmal 259 

Folliculitis 236, 238 

barbae 237 



440 



INDEX. 



PAGE 

Fragilitas crinium 308 

Freckles 261 

Frost-bite 162 

Functional disorders 54 

Furoncle 173 

Furuncle 1 73 

Furunculosis 1 73 

Funtnkel 1 73 

Gale 116 

Gcfdssmal 273 

Gesckwiilste , . . 35 

Geschwiire 37 

Glanzhaui 287 

Glossy skin 286, 287 

Glycerin Cream 317 

Glyco-gelatin 43, 44 

Gommes scrofuleuses 181 

Granuloma fungoides 219 

Granulomata, the 1 76 

Grappling forceps 51 

Gray Oil 212 

Grutum 67 

Gum Arabic Paste 43 

Gumma, exulcerated 199 

subcutaneous 200 

superficial 199 

Gummata, multiple 204 

tubercular 182 

Giirtelrose 142 

Hair, anatomy of 22 

Hardy's Helmerieh's Ointment 120 

Hautabschnrfungen 36 

Hautfinne 228 

Hautgriesz 67 

Hauthorn 247 

Hautkrebs 279 

Hautrote 71 

Ha11tschriin.de 37 

Hantsclerem , 289 

Hebra's Cosine's Paste 284 

Hebra's Green Soap Tincture 43 

Hematidrosis 60 

Hemophilia 82 

Hemorrhages 82 

Herpes 140 

circinatus 108 

facialis 141 

febrilis 141 

i ris . . 139 

labialis 141 

preputialis 141 

progenitalis 141 

tonsurans 101 

vulvarum 141 

zoster 142 

Herpes circine 108 

Hirsuties 256 

Hives 75 

Horn, cutaneous 247 

Horny layer, the 15 

Hiihneraiige 24O 

Hydradenitis 227 

Hydroa 149 

herpetiforme 149 

Hyperemias ,.,,,., 71 



PAGE 

Hyperemias passive 73 

Hyperidrosis 56 

axillae 57 

genitalium 57 

localis 57 

manuum 57 

pedum 57 

universalis 57 

Hypertrichiasis 25b 

Hypertrichosis 25b 

Hypertrophies 241 

of connective tissue 251 

of epidermis 241 

of hair 256 

of nails 258 

of pigment 259 

Hypertrophy of sebaceous glands 254 

Hyphomycetes 9b 

Ichthyol 46 

Ichthyol-Arsenic Pills 135 

Ichthyol Collodion ■ bq 

Ichthyol Lotion 169 

Ichthyol-Mercury Ointment 113 

Ichthyol Ointment No. 1 137 

Ichthyol Ointment No. 2 1619 

Ichthyol Pills 232 

Ichthyol Spray 1(39 

Ichthyose 241 

Ichthyosis 241 

congenita 242 

hystrix 242 

serpentina 242 

Ignis sacer 142 

Ihle's Resorcin Lotion 303 

Impetigo 150 

contagiosa 151 

syphiliticum 197 

Inflammations 86 

deep-seated 159 

of glands 227 

of nails 239 

superficial 86 

Initial lesion 187 

Iodide-of-Potash Solution 213 

Iodine 48 

Iodine Mixture 213 

Iodized Glycerin 225 

Iodoform 47 

Iodoform Pills 213 

Iodoform-Tannin Powder 249 

Itch, the 116 

Jessner's Carbolic-Sulphur Ointment 307 

Joseph's Naphthol Green Soap Spirit 115 

Juchflechte 79 

Kahlheit 298 

Kaposi's Caustic Paste 284 

Kaposi's Dye Formula No. I 297 

Kaposi's Dye Formula No. 2 297 

Kaposi's Naphthol Ointment 82 

Keloid 265, 266 

Keratohyalin 15 

Keratoma 244 

Keratosis pilaris 241, 243 

Kerion 102 

Kerosene Lotion , , 121 



INDEX. 



441 



PAGE 

Keyes's Cutaneous Punch 51 

Kleienflechte 113 

Knollen 35 

Knollenkrebs 265 

Knotcn , 35 

Knotschen 34 

A'ratze lib 

Krause, end-bulbs of 19 

Krebs 277 

Kriesfleckige Kahlhtit 304 

Knisten 37 

Kuhpocken go 

Kupferfinne 233 

Kupfernase 230 

Lactic-acid Ointment 181 

Lactic-acid Solution 225 

Lanugo hair 22 

Lassar's Paste 43 

Lassar's Peeling Paste 232 

Lassar's Salicylic-acid Ointment 303 

Lassar's Sublimate Lotion 303 

Laudanum Ointment 144 

Lead Lotion 61 

Leichdorn 246 

Leichentuberkel 184 

Leiomyomata 272 

Lentigo 261 

Lepra 215 

anesthetica 217 

Arabum 215 

macular 216 

mutilans 217 

nervorum 217 

tuberosa 216 

Lepre 215 

Leprosy 215 

Lesions 33 

primary 34 

secondary 36 

Leucoderma 293-295 

acquisita 293 

congenita 293 

Leucoma unguium T 309 

Lichen lividus 181 

pilaris 241, 243 

planus 92 

ruber 94 

ruber acuminatus 94 

ruber planus 92 

scrofulosorum 181, 182 

tropicus 139 

urticatus 76 

Lime-oil 135 

Linsenflecke 201 

Lipoma 268 

pendulum 269 

polyposum 269 

Livedo 73 

Liver-spot 262 

Lotions 41 

Loupe 68 

Lupus discretus 1 78 

disseminatus 1 78 

erythematosus 221 

erythematosus aggregatus , 222 



PAGE 

Lupus erythematosus corneus 222 

erythematosus discoides 222 

erythematosus disseminatus 222 

exedens 1 78 

exfoliativus 1 78 

exulcerans 178 

hypertrophicus 1 78 

maculosus 178 

papillaris 1 78 

sebaceus 221 

seborrheicus 221 

serpiginosus 178 

tuberculosus 178 

verrucosus 1 78 

vulgaris 177 

Lupus vulgaire 177 

Lymphadenie cutane'e 219 

Lymphangioma 27b 

cavernosus 276 

simplex 27b 

Lymphatics 16 

Macrochilia 276. 

Macroglossia 276 

Maculse et striae atrophica; 28b 

Macules 34 

Marsden's Paste 46 

Maseru 86 

Masque de la grossesse 262 

Matrix of nail 28 

Measles 86 

German 87 

hybrid 87 

Meibomian glands 21 

Meissner, corpuscles of 18 

Melanoderma 262 

Melanosarcoma 270 

Mentagra 236 

Menthol 48 

Menthol Capsules 78 

Menthol-oil 174 

Menthol Ointment 5b 

Mercurial Ointment, Compound 214 

Mercurial Ointment and Powder 214 

M ercury 48 

Microspnron furfur 96, 1 14 

Miliaria crystallina 60 

Milium 67 

Mitesser 65 

Mixed Treatment 210 

Mole 259 

Molluscum contagiosum 254, 255 

fibrosum 267 

pendulum 267 

sebaceum 254 

Monilethrix 308 

Moniliform hairs 308 

Morbilli 86 

Morbus maculosus Werlhofii 83 

Morphcea 289 

Morris's Thymol-Chloroform Oil 120 

Mother's mark 273 

Mucous patch 195 

Muscles of the skin 17 

Muttermal 259 

Mycosis fungoides 219 



442 



INDEX. 



PAGE 

Myoma 272 

Myxofibroma. 268 

Myxolipoma 268 

Myxoma 208 

Myxosarcoma 268 

Noevus araneus 274 

flammeus 273 

lipomatodes 260, 274 

mollusciformis 260 

papillary 275 

pigmentosus 259, 260 

pilosus 260 

sanguineus 273 

spilus 259 

unius lateris 260 

vasculosus 273 

venosus 274 

verrucosus 259 

Nails, the 27 

Naphthol 47 

Naphthol Ointment 105, 243 

Naphtholated Oil 100 

Naphtholated Spirit 303 

A T arbe 264 

Narben ' 38 

Narbenkrebs 265 

Nassende Papel 195 

Nervennavi 260 

Nerves of the skin 17 

A'esselausschlag 75 

Nettle-rash 75 

Neuroma 268 

New growths 264 

of connective tissue 264 

of glandular tissue 276 

of muscular tissue 272 

of vascular tissue 273 

Nodositas crinium 308 

Nuclear layer 15 

CEdemas 74 

Ointments 42 

Oleate of Mercury Ointment 210 

Onychatrophia 309 

Onychauxis 258 

Onychia 239 

maligna 239 

syphilitica 200 

Onychogryphosis 258, 290 

Onychomycosis 240 

favosa 97 

Pachydermia 251 

Pacinian bodies 18 

Paget's disease 287 

Panniculus adiposus 16 

Papillse of the skin 15 

Papillary layer of the skin 15 

Papilloma, malignant 280 

Papules 34 

Parasiticides 45 

Paronychia 239 

syphilitica .*. . 200, 202 

Paschkis's Hair-dye No. 1 297 

Paschkis's Hair-dye No. 2 297 

Pastes 43 

Pediculidc? , 120 



PACB 

Pediculosis 1 20 

capitis 1 20 

corporis 122 

pubis 124 

vestimenti 122 

Pediculus capitis 120 

corporis 122,123 

pubis 124 

Pelade 304 

Peliosis rheumatica , 83 

Pemphigus 145 

diphtheritica 147 

foliaceus 147 

hemorrhagicus 145 

leprosus 21b 

pruriginosus 148 

solitarius 145 

syphiliticus 203 

vegetans 147 

vulgaris 145 

Perifolliculitis 23b 

Permanganate Gargle 214 

Pernio 73, ib2 

Peru-Balsam Ointment 138 

Petite ve'role 89 

Petite ve'role volatile 91 

Pfitndnase 233 

Phtheiriasis 120 

capitis 1 20 

inguinalis 124 

pubis 124 

vestimenti 122 

Physiology 29 

PifT ard's Tar Lotion 303 

Pigment of the skin 19 

Pigmentary ncevus 259 

Pigmentmal 259 

Pili annulati 296, 308 

Pink Pigment No. I 320 

Pink Pigment No. 2 320 

Pityriasis capitis 300 

pilaris 243 

rosea no 

rubra 152 

tabescentium 287 

versicolor 113 

Plaque muqueuse 195 

Plaques ortie'es 36 

Plaster-muslins 43 

Plasters 44 

Poliosis 294, 295 

circumscripta 293 

Polytrichia 256 

Pompholyx 144 

Porrigo contagiosa 151 

decalvans 304 

Port-wine stain 273 

Post-mortem tubercle 184 

Prairie itch 55 

Prescriptions. 

No. I. Vleminckx's Solution 43 

2. Lassar's Paste 43 

3. Gum Arabic Paste 43 

4. Glyco-gelatin 43 

5. Hebra's Green Soap Tincture 43 



INDEX. 



443 



No. 6. 

7- 
8. 

9- 
io. 



13- 
14. 

IS- 
16. 

17- 
18. 
19. 
20. 



23- 

24. 

25- 

26. 
27. 
28. 
29. 
3°- 
31- 
32. 

33- 
34- 
35- 
3&- 
37- 
38- 
39- 
40. 
41. 
42. 

43- 

44. 

45- 
46. 

47- 
48. 
49. 
50. 
5i- 
52- 
53- 
54- 
55- 
5&- 
57- 
5*- 
59- 
60. 
61. 
62. 
63- 
64. 
65. 
66. 
67. 
68. 
69. 
70. 



Asiatic Pill 46 

Marsden's Paste 46 

Ungt. Chrysarobini Comp 46 

Calomel Suspension 46 

Tar Spirit 56 

Carbolic Lotion i;6 

Menthol Ointment 56 

Veratria Ointment 56 

Salicylic Dusting Powder 58 

Alum Dusting Powder 58 

Quinine Dusting Powder 58 

Lead Lotion 61 

Zinc Dusting Powder 61 

Startin's Mixture 64 

Resorcin Ointment 64 

Tannin-Resorcin Spirit 64 

Tar Ointment 64 

Bronson's Mercurial Ointment 64 

Sulphur Paste 64 

Sulphur Ointment 64 

Simple Ointment 70 

Salol-Menthol Oil 70 

Sack's Camphor Ointment 74 

Boracic-acid Ointment 74 

Saline Draught 78 

Atropia Pills 78 

Menthol Capsules 78 

Saalfeld's Menthol Lotion 78 

Carbolic Spirit 78 

Chloral Lotion 78 

Chloral-Camphor Ointment 78 

Kaposi's Naphthol Ointment 82 

Wilkinson's Ointment 82 

Unna's Carbolic-Sublimate Ointment. 94 

Chrysarobin Ointment 94 

Naphtholated Oil 100 

Resorcin-Salicylic-Sulphur Paste .... 100 

Sublimate Ointment 100 

Pyrogallol Ointment 100 

Compound Tar Spirit 104 

Sulphur-soap Spirit 104 

Copper Oleate Ointment 105 

Naphthol Ointment 105 

Sublimate Spirit 108 

Tannin-Sulphur Paste 108 

Chrysarobin Collodion 108 

Morris's Thymol-Chloroform Oil .... no 

Ichthyol-Mercury Ointment 113 

Zinc Paste 113 

Joseph's Naphthol Green Soap Spirit 115 

Sodic Hyposulphite Lotion 115 

Scabies Ointment 120 

Hardy's Helmerich's Ointment 120 

Kerosene Lotion 121 

Duhring's Staphisagria Ointment ... . 124 

Rosenbach's Lotion for Pediculosis . . 125 

Diuretic Mixture 134 

Ichthyol-Arsenic Pills 135 

Zinc-Camphor Powder 135 

Zinc-oil 135 

Lime-oil 135 

Alkaline Lotion 135 

Cooling Salve 135 

Rose-water Ointment 135 

Salicylic-Menthol Paste 136 



No. 71. 
72. 
73- 

74- 
75- 
76. 

77- 
78. 

79- 
80. 
81. 

82. 

83- 
84. 

85- 
86. 
87. 



90. 

91. 
92. 

93- 
94. 

95- 
96. 

97- 
98. 
99. 

100. 

101. 

102. 

103. 

104. 

105. 

106. 

107. 

108. 

109. 

no. 

III. 

112. 

"3- 

114. 

"5- 
116. 
117. 
118. 
119. 
120. 
121. 
122. 
123. 
124. 
125. 
126. 
127. 
128. 
129. 
130. 

131- 

132. 

133- 
134- 
135- 



PAGE 

Diachylon Ointment 136 

Ichthyol Ointment 137 

Calaxine Lotion 137 

Peru-Balsam Ointment 138 

Tar Paste 1 38 

Duhring's Morphine Collodion 144 

Laudanum Ointment 144 

Unna's Soft Zinc Paste 149 

Salicylic-Sulphur Paste 153 

Diuretic Mixture 158 

Duhring's Arsenic Mixture 158 

Ichthyol Arsenic Pills 158 

Pyrogallol Collodion 158 

Carron-oil 165 

Ichthyol Collodion 165 

Duhring's Poison-ivy Lotion 165 

Ichthyol Collodion 169 

Ichthyol Ointment No. 2. 169 

Ichthyol Lotion 169 

Ichthyol Spray 169 

Menthol-oil 174 

Lactic-acid Ointment 181 

Pyrogallol Ointment No. 2 181 

Cinnamonic-acid Injection 181 

Crocker's Lead Thymol Ointment . . . 183 

Antiseptic Mouth Wash 209 

Astringent Mouth Wash 209 

Protiodide Pill 210 

Mixed Treatment 210 

Calomel Powders 210 

Oleate of Mercury Ointment 210 

Sublimate Injection 212 

Salicylate-of-mercury Suspension .... 212 

Gray Oil 212 

Iodide-of-Potash Solution 213 

Iodoform Pills 213 

Iodine Mixture 213 

Syrup of the Iodide of Iron 213 

Compound Mercurial Ointment 214 

Mercurial Ointment and Powder .... 214 

Black Wash 214 

Sublimate Gargle 214 

Permanganate Gargle 214 

Arsenic Solution 220 

Sodium Arseniate Solution 220 

Camphor-Naphthol . . . . . 220 

Cade-Sulphur-Green Soap Ointment. . 225 

Lactic-acid Solution 225 

Iodized Glycerin 225 

Ichthyol Pills 232 

Lassar's Peeling Paste 232 

Sulphur Lotion 233 

Resorcin Ointment No. 2 243 

Salicylic-acid Ointment 243 

Naphthol Ointment 243 

Salicylic-soap Ointment 245 

Salicylic-Cannabis Collodion 245 

Iodoform-Tannin Powder 249 

Sublimate Collodion 251 

Duhring's Depilatory 257 

Bulkley's Lotion 261 

Hebra's Cosme's Paste 284 

Kaposi's Caustic Paste 284 

Cocaine Ointment 28S 

Paschkis's Hair-dye No. I 297 



444 



INDEX. 



139- 
141. 
142. 

143- 
145. 

147- 
148. 
149. 
150. 
151. 
l S 2 - 
*53- 



No. 136. I'aschkis's Hair-dye No. 2 297 

137. Anderson's Hair-dye No. I ; 138. No. 2 297 
Kaposi's Dye Formula No. I ; 140. No. 2 297 

Pyrogallol Hair-dye 297 

Stimulant Lotion 303 

Sodic Bicarbonate Lotion; 144-Quinine 303 
Ihle's Resorcin ; 146. Piffard's Tar Lotion 303 

Tannic-acid Ointment 303 

Sublimate Ix>tion 303 

Lassar's Sublimate Lotion 303 

N.iphthol Spirit 303 

Lassar's Salicylij-acid Ointment 303 

Croton oil Ointment .... 307 

Bulkley's Carb.dic- Iodine Application. 307 

154. Jessner's Carbolic -Sulphur Ointment.. 307 

155. Sapo Supsradiposus 314 

156. Lanolin Emulsion 314 

157. Hager's Glycerin Paste 314 

158. Toilet Water, 314; 159. Face Lotion . 315 
160. Borax Lotion. No. 1; 161. No. 2 315 

162. Detergent Solution ..... 315 

163. Cologne Vinegar; 164. Aromatic Vinegar 316 
165. Massage Ointment; 166. Soap Essence 316 

167. Bjrax Soap Spirit 316 

168. Bichloride Hair Wash 316 

169. Quinine Spirit 316 

Stimulant Hair Wash 3 16 

Stimulant Hair Ointment; I72.HairOil 317 

Glycerin Cream 317 

Adeps Lanse Cream; 175. Inunction Oil 317 

Adeps Lanse Cream No. 2 317 

Lanolin Cream 318 

Bernatzik's Crystal Pomade 318 

White Face Powder 318 

Almond-meal Powder 318 

Glycerin Cold Cream 318 

182. Debay's Pomade; 183. Rose Pomade. . 318 

184. Brilliantine; 185. Hair Oil 318 

Face Powder 320 

Magnesia Face Powder 320 

Carmine Face Powder 320 

Princess Water 320 

Pink Pigment No. 1; 191. No. 2 320 

Rusma Depilatory Paste 322 

Redwood's Depilatory 322 

Boudet's Depilatory 322 

Depilatory Powder 322 

Neumann's Depilatory 322 

Debay's Depilatory 322 

Depilatory Water . 322 

Boettger's Depilatory 322 

Prickle-cell layer 15 

Prickly heat 139 

Princess Water 320 

Protiodide Pill 210 

Prurigo 70 

agria ; ferox; mitis 81 

Pruritus — aestivus; hiemalis; senilis; universalis 54 

ani ; localis ; vulvae .... 55 

Psoriasis 153 

annularis; buccalis; diffusa; figurata; guttata; 
gyrata; nummularis; punctata; serpiginosa; 

universalis igfj 

Purpura — hemorrhagica; rheumatica; simplex.. 83 
scorbutica 84 



170. 
171. 

173- 
174. 
176. 
177. 
178. 
179. 
180. 
181. 



186. 
187. 
188. 
189. 
190. 
192. 

*93- 
194. 

195- 
196. 
197. 
198. 
199. 



Purpura urticans 76 

Pusteln 36 

Pustules 36 

Pyrogallol 47 

Pyrogallol Collodion 158 

Pyrogallol Hair-dye 297 

Pyrogallol Ointment No. I 100 

Pyrogallol Ointment No. 2 181 

Quaddeln 36 

Quinine Dusting Powder 5^ 

Quinine Lotion 303 

Radix 24 

Resorcin 47 

Resorcin Ointment No 1 64 

Resorcin Ointment No. 2 243 

Resorcin-Salicylic-Sulphur Paste 100 

Rete Malpighii 15 

mucosum 15 

Reticular layer 16 

Rhagaden 37 

Rhinophyma 233, 234 

Rhinoscleroma 225 

Rhus toxicodendron 1 64 

venenata 164 

Ringed hair 296 

Ringelhaare 3 & 

Ringworm of the beard 105 

of the body 108 

of the crotch no 

of the head 107 

Rodent ulcer 278 

Rosacea 233 

Rose 107 

Rosenbach's Lotion 125 

Roseola 73 

annulata 192 

figurata 192 

syphiliticum 19 2 

Rose-rash 7 1 

Rose-water Ointment 135 

Rotheln 87 

Rotlauf 167 

Rougeole 86 

Rubeola 87 

Rubeole 87 

Rupia syphilitica 196 

Saalfeld's Menthol Lotion 78 

Sack's Camphor Ointment 74 

Salicylate-of-Mercury Suspension 212 

Salicylic Acid 47 

Salicylic-acid Ointment 243 

Salicylic-Cannabis Collodion 245 

Salicylic Dusting Powder 58 

Salicylic-Menthol Paste 136 

Salicylic-soap Ointment 245 

Salicylic-Sulphur Paste 153 

Saline Draught 7& 

Salol-Menthol Oil 7° 

Salt rheum 125 

Salve-muslins 43 

Salve-pencils 44 

Salzfluss 125 

Sarcoma 270 

melanotic 2 70 

Sarcomatosis cutis 270 



INDEX. 



445 



FACE 

Scabies Ii6 

Scabies Ointment 120 

Scabs 37 

Scales 37 

Scapus 23 

Scar 264 

Scarf-skin 14 

Scarificator 50 

Scarlatina 87 

Scarlatine 87 

Scarlet fever 87 

Scars 38 

Sc hanker, weicher 1 70 

Scharlach 87 

Schleimpapel 195 

Sckuppcn 37 

Schuppenflechte 153 

Schweile 244 

Scissura pilorum 308 

Sclerema adultorum 289 

neonatorum 291 

of the new-born 291 

Sclerodactylie 290 

Scleroderma 289 

circumscriptum 289 

neonatorum 29 1 

universalis 290 

Sclerodermic 289 

Sclerosis 187 

Scrofulide hiberculeicse 177 

Scrofuloderma 181 

papulosum 182 

pustulosum 182 

tubero-ulcerosum 182 

ulcerosum 182 

Scurvy 84 

land 83 

Sebaceous cyst 68 

Sebaceous glands 20 

Seborrhea 61 

capitis 62 

congestiva 221 

faciei 63 

genitalium 63 

nasi 63 

oleosa 61 

sicca 62 

Sebum 20 

Shingles 142 

Simple Ointment 7° 

Smallpox 89 

Sodic Bicarbonate Lotion 303 

Sodic Hyposulphite Lotion 115 

Sodium Arseniate Solution 220 

Sommersprossen 261 

Spitzencondylom 248 

Spud 51 

Squames 37 

Stains 38 

Startin's Mixture 64 

Steatoma 68 

Steatorrhea 62 

Stimulant Hair Ointment 317 

Stimulant Hair Wash 316 

Stimulant Lotion 303 



PAGE 

Stratum corneum 15 

Stratum granulosum 15 

lucidum 15 

spinosum 15 

Streptococctis erysipelatis 167, 168 

Striae atrophica; 287 

Strophulus pruiigincux 79 

Subcutis, the 16 

Sublimate Collodion 251 

Sublimate Gargle 214 

Sublimate Injection 212 

Sublimate Lotion 303 

Sublimate Ointment 100 

Sublimate Spirit 108 

Sudamina 60 

Sudoriparous glands 21 

Sulphur 47 

Sulphur Lotion 233 

Sulphur Ointment 64 

Sulphur Paste 64 

Sulphur-soap Spirit 104 

Sweat 22 

Sweat-glands 21 

Sycosis coccygenes .'.... 23b 

non parasitica 236 

parasitica 105 

Sycosis non parasitaire 236 

Symptomatology 32 

Syphilide, erythematous 192 

macular 192 

papular 192 

Syphilides 190 

Syphilis 186 

cutanea 190 

hereditary 202 

insontium 186 

of hair and nails 200, 201 

Syphiloderma 190 

gummatosa 198 

maculosa 191, 192 

maculo-papulosa 193 

palmaris et plantaris 193 

papillomatosa 198 

papulosa 192 

papulosa, large 192 

papulosa, miliary 195 

papulo-squamosa 193 

pustulosa 195 

pustulosa, large 196 

pustulosa, miliary 197 

tuberculosa 197 

tuberculo-squamosa 198 

ulcerosa 200 

Syphiloma 198 

Syrup of the Iodide of Iron 213 

Tache de feu 273 

pigmentaire 259 

Taches 34 

de rousseur 261 

Tactile corpuscles 18 

Tannic-acid Ointment 303 

Tannin-Resorcin Spirit 64 

Tannin-Sulphur Paste 108 

Tar 46 

Tar Paste 138 



446 



INDEX. 



Tar Ointment 64 

Tar Spirit 56 

Tar Spirit, Compound 104 

Teigne favense 96 

tonsurante 101 

Telangiectasis 273 

Tetter 125 

Texas mange 55 

Therapeutics 39 

Thiol 47 

Tinea barbae 105 

circinata 108 

decalvans 304 

favosa 96 

sycosis 105 

tonsurans 101 

versicolor 113 

Trichophytie sycosique 105 

Trichophyton tonsurans 96, 101 

Trichophytosis 101 

barbre 105 

capitis 101 

corporis 108 

cruris 1 10 

Trichorrhexis nodosa 308 

Tubercles 35 

Tuberculosis cutis 177, 185 

cutis verrucosa 184 

Tnmenrs 35 

Tumor cavernosus 273 

Tumors 35 

Tyloma 244 

Tyson's glands 21 

Ulceres 37 

Ulcers 37 

Ulcus durum 187 

molle 170 

Ulerythema centrifugum 221 

Unna's Carbolic-Sublimate Ointment 94 

Unna's Soft Zinc Paste 149 

Uridrosis 60 

Urtica urens 75 

I 'rticaire 75 

Urticaria 75 

acuta 76 

alba 75 

annularis 75 

bullosa 76 

factitia 76 

figurata ... 75 

gigantica 7b 

gyrata 75 



PACE 

Urticaria hemorrhagica 76 

papulosa 76 

pigmentosa 76 

rubra 75 

tuberosa 76 

vesiculosa 76 

Vaccine 90 

Vaccinia 90 

Varicella 91 

Variola 89 

syphilitica 197 

Vater, corpuscles of 18 

Vegetations dermiqnes 248 

Venereal warts 248 

Veratria Ointment 56 

Vergetnres 287 

Verruca 250 

necrogenica 184 

planse 250 

seniles 250, 287 

Verrne 250 

Vesicles 35 

Vcsicnles 35 

Vibrissae 20 

Vitiligo 293 

Vitiligoidea 269 

Vleminckx's Solution 43 

Wagner, corpuscles of 18 

Wart 250 

senile 287 

Warze 250 

Wen 68 

Wheals 36 

White Face Powder 318 

Whitlow 239 

Wilkinson's Ointment 82 

Windpocken 92 

Wine nose 233 

Xanthelasma 269 

Xanthoma 269 

diabeticorum 270 

tuberosum 269 

Xeroderma 241, 286 

Zinc-Camphor Powder 135 

Zinc Dusting Powder 61 

Zinc-oil 135 

Zinc Paste 113 

Zona 142 

Zoster 142 

gangrenosus 143 

hemorrhagicus 143 

ophthalmicus 143 



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